HYDE PARK CENTRAL SCHOOL DISTRICT

Administration Offices

P.O. Box 2033

Hyde Park , New York 12538-8033

REQUEST FOR RE-EVALUATION OF INSTRUCTIONAL MATERIALS

Media consists of all types of print and non-print materials, including but not limited to books, films, tapes, videos, records, pictures, transparencies, Internet-based resources, and other printed or published items.

Request initiated by: __________________________________________________

Name of person, organization, or group seeking reconsideration

On behalf of: ________________________________________________________

Address: ___________________________________________________________

Title of Item: ____________________________________________________________________

Author: ______________________ Type of Material: ____________________________________

Publisher/Producer: ______________________________ Date of Publication: _______________

1. Did you read, view, or listen to the item in its entirety? _______________________________

2. How was the item used in the educational program? __________________________________

____________________________________________________________________________

(assignment, selection from a list, independent work, class viewing, etc.)

3. What is objectionable regarding the item, and why? Be specific, and include page numbers, if applicable:

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

4. Please cite references to any published commentary you have found regarding the item:

__________________________________________________________________________________

5. How do you see the item being appropriately utilized in an educational program?

_________________________________________________________________________________

6. What do you suggest be done with the item in question?

a) Do not assign it to my child.
b) Withdraw it from all students, as well as my child.
c)Other: ____________________________________________________

7. What do you suggest be provided to replace the item in question?

_________________________________________________________________________________

Please be aware that you may be requested to make a brief presentation to the Instructional Materials Review Committee.

_______________________________

Signature of Complainant/Date

11 Boice Road
P. O. Box 2033
Hyde Park, NY 12538
(845) 229-4000
For Emergency Information (845) 229-4001
District Fax: 229-4056
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