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                                                                  

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

 

                                                                               

    Dated                          Signature

 

Approved 10/20/11     Reviewed  10/19/22              Revised    8-16-23