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
