Teacher's Name    School

Date

Work Phone Number   Fax

Email address

Assignment Title

Grade    # of Students

Beginning/Ending Dates of Assignment

Please check one of the following:
Purpose of the assignment
practice using library materials with only usual librarian assistance.
information gathering with as much special attention as can be provided

Types of materials needed by the students:
books   magazines   reference materials    audiovisual materials
Web sites   reserve scarce materials in library

Library services needed by teacher:
bibliography    Web site list     class visit

Any restrictions on the types of materials used (i.e. 2 sources, only 1 can
be an encyclopedia)

Please submit this form at least 2 days
in advance of the assignment.