File: KLB-E
BUENA VISTA CITY SCHOOL DIVISION
REQUEST FOR RECONSIDERATION OF LEARNING RESOURCES
Request By: _______________________
Representing: ____ Myself
____ Organization or Group (please identify) ____________________
Address: _____________________________________________________________
Telephone: _______________________
Title or Description of Item: ___________________________________________
Author or Editor: ______________________
Type of Material (book / film / record / speaker / software / other (specify)) _________
1. Did you examine, review, or listen to this learning resource or presentation in its entirety?
YES NO
2. Have you been able to discuss this material with school staff who ordered it or who use it?
YES NO
3. Are you aware of the judgment of this material by professional critics?
YES NO
If no, would you be interested in receiving this information?
YES NO
4. Describe what prompted your concern about the material. Please cite page numbers and/or specific information from the material to support your concerns (attach additional material, if necessary).
5. Does the general purpose for the use of the material, as described by the school staff or in the BUENA VISTA CITY School Division’s program objectives, seem a suitable one for you?
YES NO
If not, please explain (attach additional material, if necessary)
6. What action[s] would you like to see the school take regarding this material?
Do not assign it to my child The school should reevaluate the material
Other--Explain
7. Are there other materials of the same subject and format that you would suggest for consideration in place of this material? YES NO
If yes, please identify your suggestions.
Signature ______________________________ Date ____________
RETURN COMPLETED FORM TO SCHOOL PRINCIPAL
© 11/98 VSBA