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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: _____________________________


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 ________________________________________

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