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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
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?
©
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?
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