Request initiated by:  ______________________________________________________________________
Address:  _________________________________________________________________________________
                  _________________________________________________________________________________
Telephone:  _______________________________________________________________________________
E-Mail Address:  ___________________________________________________________________________
Complainant represents: (check one)
______  himself/herself
______  Name of organization_________________________________________________________________
______  Identify other group__________________________________________________________________

1. To what in the work do you object? Please be specific; cite exact parts:

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2. What of value is there in this work?

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3. What do you feel might be the result of reading, viewing, or listening to this work?

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4. For what age group would you recommend this work?  ______________________________________
   
5. Did you read, view, or listen to the entire work?  ____________________________________________
            If no, what pages or section?  _________________________________________________________
   
6. Are you aware of the judgment of this work by critics?_______________________________________
   
7. Are you aware of the librarian's purpose in selecting this work?_______________________________
   
8. What do you believe is the theme or purpose of this work?

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9. What would you prefer the school do about this work?
   _____ Do not assign or recommend it to my child.
   _____ Withdraw it from all students.
   _____ Send it back to the proper department/grade level for reevaluation.

10. In its place, what work of equal value would you recommend that would convey as valuable a picture and perspective of a society or set of values?
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