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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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