Request for re-evaluation of printed or multi-media 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:____________________________________________________________
Date of Publication:___________________________
Multimedia Material, If Applicable:
Title:________________________________________
Producer:________________________________________
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:____________________
*Adopted: 12/13/10
*Reviewed: 02/10/14
*Reviewed: 01/14/19
