Request for reconsideration of media materials
Title
_____________________________________________________________________________
Author ____________________________________________________
Publisher ____________________________________________________
Year of Publication ___________________
1. Have you read, viewed, listened to or used the material in its
entirety? _________________
2. Specify what you object to in the material. Please be specific: cite
pages, for example.
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
3. What do you feel might be the result of reading, viewing or listening to
or using this material?
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
4. For what age group would you recommend this material? __________________
5. What do you think is positive about this material?
_____________________________________________________________________________
_____________________________________________________________________________
6. Are you aware of professional critics' views on this material? Please
Explain
_____________________________________________________________________________
_____________________________________________________________________________
7. What action would you like the library to take with this material?
Do not assign or lend it to my child?___________________________________
Withdraw it from the school? __________________________________________
Return it for re-evaluation? ___________________________________________
Other __________________________________________________________________
8. What material would you recommend in its place?
_____________________________________________________________________________
_____________________________________________________________________________
Signature Date
_____________________________________________________________________________
Name (printed)
______________________________________________________________
