Patron's Request for Review of Library Materials

1. Name of Complainant:________________________________________

2. Address ___________________________________________________

3. City___________________________

State __________          Zip______________

Phone __________________

4. Type of material objected to:  _____ book  _____ magazine

          _____ illustrations  _____ cassettes  _____  compact disc  _____  video

          other (describe)                                                 

5. Author:

6. Title:

7. Publisher:

8. Have you reviewed the entire work?           If no, what sections?

9. Are you aware of the judgment of this work by recognized literary critics?

10. What do you believe is the theme of this work?

11. What is your specific objection to this material?

12. Is there anything good about this material?

13. What do you feel might be the result of reading/hearing/viewing it?

14. What action would you recommend be taken regarding the use of this material?

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

16. Other comments

Signature:_________________________________________

Date: _______________

Reviewed by the Director: ___________________________

Date: _______________

Recommendation of the Director:

Copy Sent to Complainant:        ________________(Date)

Copy Sent to Board:        _____________(Date)

Appealed:                         ___________________