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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:_______________



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:_____



Date of Publication:________________________________________

Multimedia Material, If Applicable:



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 _____       (a)        Please contact the Superintendent

                      (b)        Please be prepared at this time to indicate the approximate length of time your presentation will require.

                                 Minutes __________

No _____

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:____________________