Challenge of Materials in the Harris-Elmore Public Library or Genoa Branch Library
(Please Print and bring back to the library Front Desk)
Name of Complainant: _____________________________
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 ______________________________________________________________________________
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).