605.3E2 Reconsideration of Instructional And Library Materials Request Form

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

Review Initiated By:                                                                            Date:_______________

Name:________________________________________Telephone:_____________________

Address:__________________________________City/State:________________Zip Code:________

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

Book or Other Printed Material, If Applicable:

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

Title:________________________________________Publisher:_____________________________

Date of Publication:_____________________________ 

Multimedia Material, If Applicable:

Title:________________________________________ Producer:_____________________________ 

Type of material (video, online resource, 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   (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 be allowed to present to the committee, or that you will get your requested amount of time.  Minutes requested: __________

___________ No 

Signature:_______________________________________                  Date:____________________