Request for re-evaluation of printed or audiovisual material to be submitted to the superintendent.
REVIEW INITIATED BY:
DATE:
Name ______________________________________
Address ______________________________________
City/StateZip 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 ______________________________________
AUDIOVISUAL MATERIAL IF APPLICABLE:
TitleProducer (if known) ______________________________________
Type of material (filmstrip, motion picture, etc.) ____________________________________
PERSON MAKING THE REQUEST REPRESENTS: (circle one) Self, Group or Organization
Name of group ______________________________________
Address of Group ______________________________________
1.What brought this 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 this 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 No
If Yes (a) Please call the office of the Superintendent
(b) Please be prepared at this time to indicate the approximate length of time your presentation will require.______ Minutes
Although this is no guarantee that you’ll be allowed to present to the committee, or that you will get your requested amount of time. '
Dated ___________ Signature ______________________________________
Approved __________
Reviewed________
Revised _______
