CITIZENS REQUEST FORM FOR RE-EVALUATION OF MATERIALS
Telephone______________________ Representing: Self?_________ Organization?__________________
School where materials are used____________________________
Grade level used________________________________________
Author of the material in question____________________________
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?______________________________
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?