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
