Date

TYPE OF MATERIAL (Please circle one):

Book DVD Magazine Audiobook Ebook CD Software Electronic

Other (please specify)

TITLE:

AUTHOR

PUBLISHER:

REQUEST INITIATED BY:

NAME

TELEPHONE

ADDRESS

Complainant represents: (check one)

Himself/herself

Organization (Name)

Other (please specify)

Use back of page or attach additional pages as needed to answer the following questions.

1. What do you object to in the work? Please be specific: cite pages, passages, etc

2. What of value is there in this work?

3. What do you feel might be the result of reading/viewing/listening to this work?

4. For what age group would you recommend this work?

5. Did you read/listen to/view the entire works?

6. Are you aware of the judgement of this work by critics?

7. What do you believe is the theme or purpose of this work?

8. What would you prefer the library do about this work?

9. What work do you believe should be added to counterbalance the viewpoint?

expressed in this work?