EDUCATIONAL PROGRAM
605.3E2 - RECONSIDERATION OF INSTRUCTIONAL MATERIALS
RECONSIDERATION REQUEST FORM
Request for re-evaluation of printed or audiovisual 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
Title ________________________________________________________________
Publisher (if known) ____________________________________________________
Date of Publication ____________________________________________________
AUDIOVISUAL 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 ____________________________________________________
PLEASE RESPOND TO THE FOLLOWING QUESTIONS.
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 of additional experts:
____________________________________________________________________
_____________________________________________________________________
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 No
(a) If yes, please call the office of the Superintendent.
(b) If yes, please be prepared at this time to indicate the approximate length of time your presentation will require.
__________ minutes.
Dated Signature