Code No. 605.3E2
RECONSIDERATION OF INSTRUCTIONAL AND LIBRARY MATERIALS
REQUEST FORM
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 (filmstrip, online resources, 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 intended?
________________________________________________________________________________________________________________________________________________________________________
Do you wish to make an oral presentation to the Review Committee? Yes (a) Please call the office of the Superintendent
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. Although this is no guarantee that you’ll be allowed to present to the committee or that you will get you requested amount of time.
_______________minutes
No ________
____________________________ ______________________________________________________
Dated Signature
Approved 9-13-93 Reviewed 6-5-13 Revised 7-25-2022