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622 Reconsideration of Instructional Materials Reconsideration Request Form

Request for re-evaluation of printed or multi-media material to be submitted to the superintendent

 

Review Initiated By:                                                                            Date:_______________

 

 

Name:________________________________________Telephone:_____________________

 

 

 

Address:__________________________________City/State:________________Zip Code:________

           

                                    Relationship to school

School(s) in which item is used:__________________________(parent, student, citizen, etc.):______

 

Book or Other Printed Material, If Applicable:

 

Author:____________________________    Hardcover:_____ Paperback:_____       Other:_____

 

 

Title:________________________________________Publisher:_____________________________

 

 

Date of Publication:_____________________________  Multimedia Material, If Applicable:

circle all 

that apply:

music

video

artwork

other:

     

 

 

Title:________________________________________Producer:_____________________________

 

 

Type of material (filmstrip, motion picture, etc.):______________________________

 

 

Person Making the Request Represents: (circle one)   Self Group or Organization           

 

Name and Address of Group or Organization:_________________________________________

 1.  What brought this item to your attention?

 

 

 

 

 

2.  To what in the item do you object? (please be specific -- cite pages, 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 contact the Superintendent  (b) Please be prepared at this time to indicate the approximate length of time your presentation will require. Minutes __________

The committee will review your request and notify you if your request is granted; however, there is no guarantee that each and every request will be granted, either in terms of appearing before the committee or in receiving the amount of time requested.

 

 

 

 

 

 

Signature:_______________________________________                  Date:____________________

 

Approved:     9/23/2019                           Reviewed:                     Revised: