605.03E2 - Reconsideration of Instructional and Library Materials Request Form

605.03E2 - Reconsideration of Instructional and Library Materials Request Form

Request for re-evaluation of printed or multimedia material to be submitted to the superintendent.

REVIEW INITIATED BY:                                                                                                      DATE:                       

Name:  _________________________________________________________________________________

Address:  _____________________________________________________________________________________

City/State:  __________________________________  Zip/Code:  _____________  Telephone:  ________________

School(s) in which item is used  ___________________________________________________________________

Relationship to school (parent, student, citizen, etc.)  ___________________________________________________

 

BOOK OR OTHER PRINTED MATERIAL IF APPLICABLE:

Author:  ___________________________________  Hardcover: ________  Paperback  ________  Other ________

Title:  ________________________________________________________________________________________

Publisher (if known)  ____________________________________________________________________________

Date of publication  _____________________________________________________________________________

 

MULTIMEDIA MATERIAL IF APPLICABLE:

Title:  ________________________________________________________________________________________

Producer (if known)  ____________________________________________________________________________

Type of material (dvd, software, website, online resources, etc.)    ___________                      

 

PERSON MAKING THE REQUEST  REPRESENTS:  (circle one)

     Self                                                                      Group or Organzation

     Name of group  ____________________________________________________________________________

     Address of group  __________________________________________________________________________

 

1.  What brought the item to your attention?
     _________________________________________________________________________________________
     _________________________________________________________________________________________

2.  To what in the item do you object?  (please be specific; cite pages or frames, etc.)
     _________________________________________________________________________________________
     _________________________________________________________________________________________

3.  In your opinion, what harmful effects upon students might result from use of this item?
     _________________________________________________________________________________________
     _________________________________________________________________________________________

4.  Do you perceive any instructional value in the use of this item?
     _________________________________________________________________________________________
     _________________________________________________________________________________________

5.  Did you review the entire item?  If not, what sections did you review?
     _________________________________________________________________________________________
     _________________________________________________________________________________________

6.  Should the opinion of any additional experts in the field be considered?
                   _____  yes                      _____  no
     If yes, please list specific suggestions:  __________________________________________________________
     _________________________________________________________________________________________

7.  To replace the item, do you recommend other material which you consider to be of equal or superior quality for
     the purpose intended?
     _________________________________________________________________________________________
     _________________________________________________________________________________________

8.  Do you wish to make an oral presentation to the Review Committee?
     _____  Yes  (a)  Please contact the superintendent

                         (b)  Please be prepared at this time to indicate the approximate length of time your presentation will
                                require.  Although this is no guarantee that you will get your requested amount of time.
                                                                                      ________________________  Minutes

     _____  No

 

_____________________________________     _____________________________________________________
Date                                                                                            Signature

 

dawn.gibson.cm… Tue, 02/23/2021 - 13:18