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RECONSIDERATION REQUEST FORM Request for re-evaluation of printed or multimedia material to be submitted to the superintendent. |
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REVIEW INITIATED BY: DATE: __________ |
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Name: _______________________________________________________ |
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Address: |
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City/State Zip Code Telephone ______________ |
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School(s) in which item is used ______________________________________ |
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Relationship to school (parent, student, citizen, etc.) ______________________________________________________________ |
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BOOK OR OTHER PRINTED MATERIAL IF APPLICABLE: |
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Author _____________________________Hardcover___ Paperback___ Other___ |
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Title_____________________________________________________ |
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Publisher (if known)_________________________________________ |
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Date of Publication___________________________ |
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MULTIMEDIA MATERIAL IF APPLICABLE: |
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Title |
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Producer (if known)_______________________________________________ |
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Type of material (filmstrip, motion picture, etc.)__________________________ |
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PERSON MAKING THE REQUEST REPRESENTS: (check one) |
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______Self ______Group or Organization |
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Name of group___________________________________________________ |
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Address of Group ________________________________________________ |
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1 |
What brought this item to your attention? __________________________________________________ __________________________________________________ __________________________________________________ __________________________________________________ |
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2 |
To what in the item do you object? (please be specific; cite pages, or frames, etc.) __________________________________________________ __________________________________________________ __________________________________________________ __________________________________________________ |
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3 |
In your opinion, what harmful effects upon students might result from use of this item? __________________________________________________ __________________________________________________ __________________________________________________ __________________________________________________ |
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4 |
Do you perceive any instructional value in the use of this item? __________________________________________________ __________________________________________________ __________________________________________________ __________________________________________________ |
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5 |
Did you review the entire item? If not, what sections did you review? __________________________________________________ __________________________________________________ __________________________________________________ __________________________________________________ |
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6 |
Should the opinion of any additional experts in the field be considered? ____ yes ____ no If yes, please list specific suggestions: __________________________________________________ __________________________________________________ __________________________________________________ __________________________________________________ |
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7 |
To replace this item, do you recommend other material which you consider to be of equal or superior quality for the purpose intended? __________________________________________________ __________________________________________________ __________________________________________________ __________________________________________________ |
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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'll be allowed to present to the committee, or that you will get your requested amount of time. _____ No |
Dated Signature___________________________________
