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:__________________________________
Cross References:
213 Public Participation in Board Meetings
Approved: 12-16-2015 Reviewed: 08/14/2023 Revised: 08/14/2023