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Appendix II - Request for Re-evaluation of a Learning Resource


Name  _________________________________________              Date  _____________________


Address  ______________________________________________________________________    


City  __________________________________________               Postal Code  _______________


Phone  ________________________________________


Do you represent yourself?   ______      Organization (name) __________________________


Learning Resource in Question:


Author     ____________________________________________________


Title         ____________________________________________________


Format     ____________________________________________________


Please respond to the following questions.   If sufficient space is not provided, you may                                                                             attach additions to this form.


How did this learning resource come to your attention?




Have you read/heard/seen this learning resource in its entirety?   Yes _____    No ___




If you have indicated No above, what parts of the resource have you read/heard/seen?




To what do you object?   Please be specific with your concerns – cite pages, passages, etc.




What do you believe is the main idea of this learning resource?




What do you feel might result from the use of this learning resource?




What do you consider the positive qualities of this learning resource?




Are you aware of the judgment of this learning resource by professional reviewers or professional educators?




For what age group would you recommend this resource?




What action do you recommend that the school take with regard to this learning resource?

_____ withdraw or exempt it from use by my child

_____ withdraw or exempt it from all students

_____ submit it to a re-evaluation committee for re-evaluation


Are there resource(s) you can suggest to provide additional information and/or other viewpoints                                                                           on this topic?




Name (print please)  ___________________________________


Signature  ____________________________________________


Date  ________________________________________________



Reviewed July 2010