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 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?
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
*Revised: 09/25/23