REQUEST FOR RECONSIDERATION OF LIBRARY MATERIAL
AUTHOR____________________________________________________________________________________
TITLE_______________________________________________________________________________________
PUBLISHER____________________________________________ COPYRIGHT DATE_____________________
CALL NUMBER OF BOOK____________________________ HARDCOVER__________________
_____________________________ PAPERBACK___________________
NAME OF SCHOOL BUILDING WITH TITLE IN SCHOOL LIBRARY MEDIA COLLECTION
____________________________________________________________________________________________
REVIEW REQUEST INITIATED BY:
NAME_______________________________________________________________________________________
ADDRESS___________________________________________________________________________________
CITY__________________________________________ STATE____________________ ZIP_______________
HOME PHONE___________________________ BUSINESS PHONE________________________EXT._______
Complainant Represents:
1. Himself/herself: YES__________ NO__________2. Other than himself/herself YES__________ NO__________
3. If yes was marked on #2, give name of group &/or person_____________________________________________
Address or group &/or person___________________________________________________________________
City____________________________________________ State____________________ Zip______________
Phone number of group &/or person ______________________________________ Extension____________
If you need more space for any answers, please use back side of sheet or attach a separate page.
1. Have you read the entire book? YES__________ NO__________
2. If yes, give a summary of the book in your own words.
3. To what in the book do you object? Please be specific and cite pages.
4. What do you feel might be the result of reading this book? Please be specific and cite pages.
5. What do you like or find positive about this book? Please be specific.
6. Is there any age or group that should be allowed access to this book? If yes, who or what group? Please be specific and explain your reasoning.
7. Is there any age or group that should not be allowed access to this book? If so, who or what group? Please be specific and explain your reasoning.
8. Have you read any review of the material and if so, please list the source and date of the review. Yes____No____
LIST INFORMATION BELOW ABOUT REVIEWS FOUND FOR THIS MATERIAL
Source of Review(s) Date of Sources(s)
9. Are you aware of the judgment of this book and/or of this author by literary critics? Write what you know about these literary opinions.
10. What would you like the school to do about this book?
11. Can you recommend another title for the school library to purchase to present the opposite, or an alternative, point of view of the title in question? YES_______________ NO_______________
12. If number 11 was answered yes, please give the following information:
Title________________________________________________________________________________
Author______________________________________________________________________________
Publisher____________________________________________________________________________
Copyright Date_______________________________________________________________________
ISBN (International Standard Book Number)_______________________________________________
Review Source_______________________________________________________________________
Date_______________________________________ Page(s)__________________________________
SIGNATURE____________________________________________ DATE______________________