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Code No. 605.3E2 Reconsideration Request Form

Reconsideration Request Form

Request for re-evaluation of instructional 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 or Organization  _______________________________________

Address of Group or Organization ______________________________________

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

(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  _______________

 

__________________________________________            ________________________

Signature                                                                                 Dated

 

Approved:  October 19, 1998

Revised/Reviewed:  February 27, 2023