Citizen
Request for Reconsideration of
Title
of Work: _______________________________________________
Author:
____________________________________________________
Publication Date:
_________________
Format: ____________________
Request Initiated
by:___________________________________________
Phone:
____________________
Address:____________________________________________________
Complainant
represents: ______his/herself
______organization (listed below)
_______________________________________
What do you find
objectionable about the above listed material?
Please be specific.
What do you feel
might be the result of borrowing this item from the library?
Is there anything
good about this item?
Did you read/view
the entire item? If not, what parts?
What do you think
is the theme of this item?
What item would
you recommend to take the place of the above challenged item?
_______________________________________ ____________________
Signature of
Complainant Date
Received by:
_______________________________________ ____________________
Signature of Staff member Date