CITIZENS REQUEST FORM FOR RE-EVALUATION OF MATERIALS
- Initiated by __________________________
- Address __________________________________________________________
- Telephone ____________ Representing: Self?______ Organization?____________________
- School where materials are used ____________________
- Grade level used________
- Author of the material in question __________________________
- Title ___________________________________________
- Copyright date _______________
- Publisher _______________________________________
- AV Materials; Kind of media _________________________________________________________
(film, filmstrip, record, etc.)- Other materials or presentation; identify _____________________________________________________
- Please respond to the following questions. If sufficient space is not available, please use back of this sheet or additional sheet of paper.
- 1. Have you read, seen, viewed, listened to this material in its entirety?
- 2. What do you believe is the main idea of this material?
- 3. To what do you object? Please cite specific passages, pages, sequences, etc.
- 4. What do you feel might result from use of this material?
- 5. Are you aware of reviews of this material? What reviews have you read?
- 6. Was the material required? _____________ Recommended?_______________
- By whom___________________________
- 7. For what grade level might this be suitable?__________________________
- 8. What action would you prefer that the school take on this material?
- a. Do not assign it to my child
- b. Other
- 9. In its place, what material do you recommend which would provide adequate information on the subject or as a valuable picture and perspective of our society?
- DATE ____________________ SIGNATURE _______________________
- Return to Table of Contents
