Appendix+F


 * || **Appendix F** || ||
 * ===PUBLIC CONCERNS / COMPLAINTS ABOUT INSTRUCTIONAL RESOURCES===

RECONSIDERATION REQUEST FORM
request for reevaluation of printed or audiovisual material Review material in its entirety before completing the following. Fill in all applicable information

Author _________________________________________________________________ Title ___________________________________________________________________ Publisher or producer (if known) ________________________________________ Date of publication or production ________________________________________ Type of material (book, filmstrip, motion picture, etc.) ____________________ Request initiated by _____________________________________________________ Telephone _____________ Address ______________________________________ City ____________________________________________________ Zip __________ School(s) in which the item is used ______________________________________ ________________________________________________________________________ Person making the request represents � him/herself � group or organization ________________________ __________________________________________ Name of Group Address of Group

1. To what in the item do you object? Please be specific; cite pages or frames, etc.) ________________________________________________________

2. In your opinion, what harmful effects upon pupils might result from use of this item? _____________________________________________________

3. Do you perceive any instructional value in the use of this item? _________

_____________________________________________________________________

4. Should the opinion of any additional experts in the field be considered? � Yes. Please list suggestions, if any _________________________________

_____________________________________________________________________ � No. In the place of this item, would you care to recommend other material you consider to be of equal or superior quality for the purpose intended?

_____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________

5. Do you wish to make an oral presentation to the Challenged Materials committee? � Yes (a) Please call the office of the librarian ______________________ (Telephone Number) (b) Please be prepared at this time to indicate the approximate length of time your presentation will require. � No. __________________________________________________________________ Date Signature Adopted: date of manual adoption ||