605.03E(2) - 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 (website, online resource,

filmstrip, motion picture, etc.)                                        _______________________________________________

 

PERSON MAKING THE REQUEST REPRESENTS: (circle one)

 

Self                                                      Group or Organization

 

Name of group ____________________________________________________________________

 

Address of Group __________________________________________________________________

 

 

 

 

1. What brought this item to your attention?

 

_______________________________________________________________________________________________

 

_______________________________________________________________________________________________

 

2. To what in the item do you object? (please be specific; cite pages, or 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'll be allowed to present to the committee, or that you will get your requested amount of time.

 

                                    ____________ Minutes.

 

____________ No

 

___________________________________________________               _______________________________________
Dated                                                                                                                                                     Signature

 

 

Approved: 9/20/2021, 11/21/2022, 11/18/2024
Reviewed: 10/21/2024
Revised: 10/21/2024