Date
Request Initiated by:
Address:
Phone: ( )
Complainant represents:
Himself/herself
Group of Organization:
Author:
Publisher:
Title:
Why do you object to this item?
To what, specifically, do you object?
Was this item recommended to you?
Did you view the entire item? If not, what parts?
Is there anything good about this item?
What do you believe to be the theme of this item?
What do you think might be the result of viewing this item?
For what age group would you recommend this item?
Are you aware of the judgment of professional critics concerning this item?
What reviews of this item have you seen?
What would you like the library to do about this item?
withdraw it from all library patrons
make it available to only certain age levels – list these:
re-evaluate the item
Do you know an item you could recommend as a suitable substitute having the same literary merit and conveying a similar perspective?
Signature of Complainant