Series 603.4P - Request for Reconsideration of Instructional Resources
Adopted: February 1987
Revised: June 2001
TO BE COMPLETED BY THE PERSON REQUESTING RECONSIDERATION: Please fill in the information requested and respond to the following questions. If more space is needed, use additional sheets of paper.
Request initiated by Phone ( )
Address City Zip
Requestor represents: self others (specify)
organization or group (specify)
Title of questioned resource
Author or creator
Publisher or producer
Copyright Type of resource (book, videotape, etc.)
1. In which school, class, grade level and subject area can this instructional resource be
2. How did you become aware of this resource?
3. Did you read, view, listen to or observe all the resource in question? If not, what parts did
you read, view, listen to or observe?
4. Do you need help obtaining a copy of the resource for you to review?
5. To what do you object about this resource? Please be specific.
6. Please comment on the resource as a whole.
7. What action do you recommend that the district take on this resource? (Circle appropriate letter.)
a. Present it at a different grade level (specify)
b. Withdraw it from all students
c. Other (specify)
8. Who have you discussed your concern with in the district (teacher, principal, etc.)?
9. Do you wish to make comments at the Reconsideration Review Committee meeting?
PLEASE RETURN THIS FORM TO YOUR PRINCIPAL.
RECEIVED BY PRINCIPAL
Signature of Principal Date School
TO BE COMPLETED BY PRINCIPAL: Please respond to the following questions and return this completed form to the director of elementary education or director of secondary education (as appropriate).
Did you offer an alternative instruction option to this person?
If yes, what was his or her response?
If no, why not?
RECEIVED BY DIRECTOR OF ELEMENTARY EDUCATION OR DIRECTOR OF SECONDARY EDUCATION