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 (website, online resource, filmstrip, motion picture, etc.) ______________
PERSON MAKING THE REQUEST REPRESENTS: (circle one)
Self Group or Organization
Name of group ________________________________________________
Address of group ______________________________________________
- What brought this item to your attention?
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
- To what in the item do you object? (please be specific; cite pages, or frames, etc.)
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
- In your opinion, what harmful effects upon students might result from use of this item?
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
- Do you perceive any instructional value in the use of this item?
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
- Did you review the entire item? If not, what sections did you review?
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
- Should the opinion of any additional experts in the field be considered? ____yes ____ no
If yes, please list specific suggestions: _____________________________________________
___________________________________________________________________________________
- To replace this item, do you recommend other material which you consider to be of equal or superior quality for the purpose intendended?
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
- 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.
_______________ Minutes
__________ No
__________________________________ ________________________________________
Dated Signature
Approved: 5/17/10
Reviewed: 9/23/15
Revised: 6/24/20; 2/23/22; 9/27/23
