#605.5F RECONSIDERATION REQUEST FORM

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, DVD, CD, motion picture, etc.) _______________________

PERSON MAKING THE REQUEST REPRESENTS: (circle one)

___________Self

___________Group or Organization

Name of group __________________________________________________________
Address of Group _________________________________________________________

RECONSIDERATION OF LIBRARY MATERIALS

1. What brought this item to your attention?
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2. To what in the item do you object? (please be specific; cite pages, or frames, etc.)
_______________________________________________________________________
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3. In your opinion, what harmful effects upon students might result from use of this item?
_______________________________________________________________________
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4. Do you perceive any instructional value in the use of this item?
_______________________________________________________________________
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5. Did you review the entire item? If not, what sections did you review?
_______________________________________________________________________
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6. Should the opinion of any additional experts in the field be considered?
____ yes ____ no
If yes, please list specific suggestions:
_______________________________________________________________________
_______________________________________________________________________
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7. To replace this item, do you recommend other material which you consider to be of equal
or superior quality for the purpose intended?
_______________________________________________________________________
_______________________________________________________________________
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Do you wish to make an oral presentation to the Review Committee?
_____ Yes
Indicate the approximate length of time your presentation will require _______minutes.

_____ No

____________________________ ____________________________
Dated Signature

Submit this form to the building Principal