Author____________________________________ Hardback, Paperback, Non-Print

Title____________________________________________________________________

Publisher (if known) ______________________________________________________

Request initiated by _______________________________________________________

Address___________________________ Telephone_____________________________

City, State, Zip___________________________________________________________

Complainant represents:

____Himself/Herself

____Name of Organization__________________________________________________

____Identify Other Group___________________________________________________

1. Did you read, listen, view the entire book or material? Yes No

2. Have you been able to discuss this material with the librarian? Yes No

3. What do you understand to be the general purpose for using this material?

-Offer a viewpoint that challenges popular thinking? Yes No

-Provide a learning experience for the reader in one kind of literature? Yes No

-Part of a well known author or artist’s body of work? Yes No

-Other____________________________________________________________

4. Did the general purpose for the use of the material, as described by the librarian, seem a suitable one to you? Yes No

5.What do you think is the author’s general purpose in this material?

6. What are your specific concerns about this material?________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

7. Have you read these two selections from the library’s policy manual: Yes No

- The Freedom to Read

-Selection and Acquisition Policy for Wood Place Public Library