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Citizen’s Request for Reconsideration of Library Material

Author ________________________________________ Format ______________________________

Title _______________________________________________________________________________

Publisher (optional) ___________________________________________________________________

Request initiated by __________________________________________________________________

Telephone _____________________________ Address _____________________________________

City ________________________________________________ Zip code _______________________

E-mail (optional) _____________________________________________________________________

Complainant represents:
______ Herself/Himself
______ Name of Organization/Group ____________________________________________________

1. Did you read, view or listen to the entire work? Yes ______ No ______

2. What do you object to in the work? (Be specific, e.g., cite pages. Use the back, if necessary.)

_____________________________________________________________________________________

3. What do you think may be the result of reading, viewing or listening to this work?

_____________________________________________________________________________________

4. For what age group do you recommend this work? _________________________________________

5. Does the Library have materials representing opposing viewpoints on this subject? Yes ___ No ___

6. Have you read reviews of this material? Yes ______ No ______

7. If so, where? _______________________________________________________________________

8. What do you think is the central theme of this work? _______________________________________

9. What would you like the Library to do about this material?
______ Do not lend it to my child.
______ Send it back to staff for re-evaluation.
______ Withdraw it from the Library’s collection.

10. In its place, what titles of equal quality on this subject would you recommend?

_____________________________________________________________________________________

_____________________________________________________________________________________
Signature of Complainant / Date

Employee’s initials _____________________ Original to Director / Copy to Assistant Director

November, 2004

 

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