RECONSIDERATION OF INSTRUCTIONAL MATERIALS
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RECONSIDERATION REQUEST FORM
Request for re-evaluation of printed or multimedia material to be submitted to the superintendent.
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REVIEW INITIATED BY: ____________________________ DATE: ____________________
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Name: _____________________________________________________
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Address: _____________________________________________________
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City/State ____________________ Zip Code ________Telephone ____________________
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School(s) in which item is used _____________________________________________________
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Relationship to school (parent, student, citizen, etc.) ____________________________________
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BOOK OR OTHER PRINTED MATERIAL IF APPLICABLE:
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Author _________________________ Hardcover___ Paperback___ Other___
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Title_____________________________________________________
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Publisher (if known)_________________________________________
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Date of Publication___________________________
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MULTIMEDIA MATERIAL IF APPLICABLE:
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Title _____________________________________________________
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Producer (if known)_______________________________________________
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Type of material (filmstrip, motion picture, etc.)__________________________
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PERSON MAKING THE REQUEST REPRESENTS: (circle one)
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______Self ______Group or Organization
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Name of group______________________________________
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Address of Group ___________________________________
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What brought this item to your attention?
__________________________________________________
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To what in the item do you object? (please be specific; cite pages, or frames, etc.)
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In your opinion, what harmful effects upon students might result from use of this item?
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Do you perceive any instructional value in the use of this item?
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Did you review the entire item? If not, what sections did you review?
__________________________________________________
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Should the opinion of any additional experts in the field be considered?
____ yes ____ no
If yes, please list specific suggestions:
__________________________________________________
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To replace this item, do you recommend other material which you consider to be of equal or superior quality for the purpose intended?
__________________________________________________
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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 will be allowed to present to the committee, or that you will get your requested amount of time. Minutes
No
Dated ______ Signature ___________________________
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Approved: 2/21/22
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Reviewed: 1/17/22
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Revised: _____
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