605.3E2 RECONSIDERATION OF INSTRUCTIONAL MATERIALS REQUEST FORM

Code

No.

605.3E2

Page 1 of 3

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

©

IASB POLICY REFERENCE

MANUAL

Code

No.

605.3E2

Page 2 of 3

RECONSIDERATION OF INSTRUCTIONAL AND LIBRARY MATERIALS

REQUEST FORM

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?