Code No. 605.3E2
RECONSIDERATION OF INSTRUCTIONAL MATERIALS
RECONSIDERATION REQUEST FORM
Lisa
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 (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
- Please contact the Superintendent
- 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: 2/8/17, Reviewed: 6/14/23, Revised:
Grinnell-Newburg School District, Grinnell, IA