RECONSIDERATION OF INSTRUCTIONAL MATERIALS
RECONSIDERATION REQUEST FORM
Request for re-evaluation of instructional materials to be submitted to the superintendent.
REVIEW INITIATED BY:
City/State : Zip Code:
School(s). in which item is used:
Relationship to school (parent, student, citizen, etc.)
BOOK OR OTHER PRINTED MATERIAL IF APPLICABLE:
Hardcover ‑ Paperback or Other:
Publisher (if known):
Date of Publication
AUDIOVISUAL MATERIAL IF APPLICABLE:
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:
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
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?
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?
(a) Please call the office of the Superintendent
Dated: ____________ Signature: ________________________________