REQUEST FOR RECONSIDERATION OF LIBRARY MATERIALS FORM

(Print this form, 2 pages)

Title ____________________________________________________________________________

Author __________________________________________________________________________

Publisher (if known) _______________________________________________________________

________ Book ________ Journal ________Other (please specify)__________________________

Request initiated by: _______________________________________________________________

Address __________________________________________________________________________

City ________________________________________________ State __________ Zip __________

Telephone # ______________________________________________________________________

Complainant represents _____Him/Herself _____Organization or group (please identify)

_________________________________________________________________________________

1. To what in the material do you object? (Please be specific; cite pages, scenes, quotations, etc.)

2. What do you believe might be the result of exposure to this material?

3. For what age group would you recommend this material?

4. Did you read/view/listen to the entire material? __________ What parts?

5. What portions of the material are worthwhile?

6. What do you believe is the theme or message of this material?

7. What material would you recommend to take its place that is of equal quality and conveys as valuable a picture and perspective of our civilization?

8. What other material have you recently read or used on the same subject?

_________________________         ___________________________________________________(Date)                                                           (Signature of complainant)

Staff member accepting request: ________________________________ Date ________________