1.‌ Name:_______________________________ ‌

2.‌ ‌Address‌ ‌_____________________________

City‌ ‌____________________‌ ‌State‌ ‌________‌ ‌Zip‌ ‌_________

3. Phone:___________________‌ ‌ ‌

4.‌ ‌Complainant‌ ‌represents:‌ ‌
a.) ‌Personal‌ ‌____‌ ‌
b)‌ ‌Organization‌ ‌(name):‌ ‌__________________‌ ‌ ‌ ‌

5.‌ ‌Type‌ ‌of‌ ‌material?‌ ‌(Book,‌ ‌DVD,‌ ‌etc.)‌ ‌____________________________________ ‌

6.‌ ‌Title: ‌ ‌_________________________________________

7.‌ ‌Author: ‌ ‌_______________________________________ ‌

8.‌ ‌Did‌ ‌you‌ ‌read/watch/listen‌ ‌to‌ ‌the‌ ‌entire‌ ‌work?‌ ‌____Yes‌ ‌____No‌ ‌ ‌ ‌

9.‌ ‌If‌ ‌not,‌ ‌which‌ ‌part(s)?:‌ ‌________________________________________________________‌ ‌ ‌ ‌

10.‌ ‌What‌ ‌concerns‌ ‌you‌ ‌about‌ ‌this‌ ‌material?‌ ‌(Please‌ ‌be‌ ‌specific;‌ ‌cite‌ ‌pages)‌ ‌  ___________________________________________________________________________‌___________________________________________________________________________‌ ‌  ___________________________________________________________________________‌ ‌ ‌

11.‌ ‌Is‌ ‌there‌ ‌anything‌ ‌positive‌ ‌about‌ ‌the‌ ‌item‌ ‌in‌ ‌question? ‌ ‌______________________________‌___________________________________________________________________________‌___________________________________________________________________________‌ ‌ ‌

12.‌ ‌What‌ ‌action‌ ‌do‌ ‌you‌ ‌think‌ ‌the‌ ‌Library‌ ‌should‌ ‌take‌ ‌in‌ ‌regard‌ ‌to‌ ‌this‌ ‌material?‌ ‌ ‌___________________________________________________________________________‌ ‌ ‌___________________________________________________________________________‌ ‌ ‌ ‌ ‌

 Signature‌ ‌of‌ ‌complainant:‌ ‌__________________________‌ ‌Date______________________‌ ‌ ‌ ‌ ‌

I‌ ‌was‌ ‌given‌ ‌a‌ ‌copy‌ ‌of‌ ‌the‌ ‌Materials‌ ‌Selection‌ ‌/‌ ‌Acquisitions‌ ‌Development‌ ‌Policy.‌ ‌Yes‌ ‌__‌ ‌No‌ ‌___‌ ‌ ‌ ‌

Return to the main policy page