Instructional Materials Request Form

All materials requested for instructional use must follow 4 basic tenets. (1) Is research-based  (2) Will be implemented according to intended research-based purpose (3) Addresses local Needs Assessment issues (4) Fits the District's Scope & Sequence

1. Request initiated by: ____________________ Campus ___________________________

2. Request is for (name of material) _____________________________________________

3. Brief statement explaining the request: _______________________________________

____________________________________________________________________________

____________________________________________________________________________

4. Type of material (circle):Textbook,  CD_ROM,  DVD, Workbook, Audio tape, Video tape, Electronic Device, Library Book  

Other (explain)_______________________________________________________________

Give author/manufacturer, title/model, publisher/manufacturer, copyright date and ISBN (if available):___________________________________________________________________

5. Have you read (or viewed) the entire material? Yes  No

If not, what parts have you read or viewed? ____________________________________________________________________________

6. Specify the research and give references that supports the use of this material. (Who used it, When, Where, How, to What Purpose, What Outcomes?

____________________________________________________________________________

____________________________________________________________________________

____________________________________________________________________________

7. How do you plan to use it? (Population, Time Frame, Minutes per day, etc.) ________

____________________________________________________________________________

____________________________________________________________________________

8. How will it fit with current curriculum? ____________________________________________________________________________

____________________________________________________________________________

9. What is the educational value in this material (device/software)?____________________________________________________________________

10. To your knowledge, what has been the judgment of qualified professional persons regarding this matter?

(Researchers, educators, book reviews, etc.) __________________________________________________________________________

11. My (our) purpose in utilizing this book/device/software is ____________________________________________________________________________

____________________________________________________________________________

12. The material/device/software will be  used in this way:________________________________________ ____________________________________________________________________________

Once you have completed this form, sign it and present it to your principal. Once your principal has signed it, it needs to be submitted to the Curriculum Director for final approval. Thank you  for your cooperation.

Date submitted __________________ Signature _________________________________

Principal's Signature:_______________________________________ Date: __________

Curriculum Director's Signature:  _____________________________Date:__________