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605.3E2 RECONSIDERATION OF INSTRUCTIONAL MATERIALS

Code No.  605.3E2

 

RECONSIDERATION OF INSTRUCTIONAL MATERIALS

 

RECONSIDERATION 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 (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

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

  1. (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