Challenge of Materials in the Harris-Elmore Public Library or Genoa Branch Library 

(Please Print and bring back to the library Front Desk)

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Date:

 

Name of Complainant: _____________________________

 

Address _______________________________________________________________ 

 

City________________________ State ______

 

Zip Code ________________

 

Phone Number ___________________ 

 

Library Card Number _____________________ 

 

Are you making this challenge as an individual?________yes ___________no 

 

Or as the representative of an organization?___________yes ___________no

 

If you are representing an organization, please provide the name and address of the organization

 

Type of item you are challenging (fill out a separate form for each item challenged):

 

Book _____ Audio _____ Video _____ 

Magazine _____ Newspaper _____ 

Computer Program _____ Other ______

 

Title of item ______________________________________________________________________________

 

Author ________________________________________

 

Publisher/Distributor/Producer ________________________________________

 

Date of Publication ________________________________________

 

What brought this item to your attention?

 

 

 

Is your objection to this item based upon your own exposure and reaction to it, upon complaints made about it directly to you by others, or upon reports you have heard about?

 

 

Have you read, viewed, or listened to this item in its entirety? 

 

If not, what portions have you read, viewed, or listened to? (List portions by page number, time into CD, or other identification)

 

 

 

 

 

      

To what specific aspects of this item do you object? Cite specific pages, passages or scenes. 

 

 

 

 

 

 

 

Can you suggest any materials to provide additional information or other viewpoints on this topic? (Use back of page and any additional space if necessary).

 

 

 

 

Signature ________________________________________

 

Date ________________________________________