Glen Oaks Elementary Video Request Form
Teachers: to determine its appropriateness for the grade level, subject matter, and relevance to instruction, you should FIRST view any video used in your class.

Date of this request: ________________________________

Teacher : ____________________________ Subject Area : ____________________________

Unit of Study : _____________________ Grade Level : ______  Room # (s) _______________

Video Title : __________________________________________________________________

Video Length : _______________________ Source (if other than library): _________________

Date video will be viewed *: _________________________________________________

Time video will be viewed *: _________________________________________________

* Reminder - teachers are responsible for scheduling their own video using the Synergy system.

This video will be used :
_____ To introduce a unit of study                               _____ For individual projects
_____ To reinforce a unit of study                                _____ For seminars
_____ To provide background for discussion               _____ To develop basic concepts in ___________
_____ To provide visual / concrete experience of abstract concepts
_____ To review a unit of study / concept
_____ To accompany a writing and / or reading selection

Please list the specific connection(s) to MISD curriculum and whether or not entire video or clip will be shown.  If the entire video is shown, please state rationale for the complete showing.
_________________________________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

Your rating of the Video : (circle one)
1. Excellent         2. Good           3. Fair          4. Poor         5. Not acceptable for this grade or subject

How many videos were/ will be used in this unit of study? _______________

Approximately how many students will view this video? _________________
APPROVAL BY (signature indicates approval prior to usage)

Mrs. Gilliam________________________    Date: _____________     

                                                 OR

Mrs. Hamilton________________________   Date:______________

Bring this form to the Media Center