School:_____________________________________________________________________

Please check type of material:

(   ) Book                                         (   ) Film                                         (   ) Record

(   ) Periodical                                 (   ) Video                                        (   ) Kit

(   ) Pamphlet                                  (   ) Cassette                                    (   ) Other

Title: ______________________________________________________________________

Author: ____________________________________________________________________

Publisher or Producer:________________________________________________________

Request initiated by:_________________________________________________________

Telephone: ___________________________Address:  _____________________________

City: _______________________________State:___________Zip:____________________

Before the following questions are answered, it is recommended that the complainant read, view, or listen to the school library material in its entirety. If sufficient space is not provided, attach additional sheets. Please sign your name to each additional sheet.

1. Have you read, viewed, or listened to this material in its entirety?

_________ Yes ________ No

What do you understand to be the term or purpose of this material?
______________________________________________________________________
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2. To what in the material do you object?

(Please be specific, cite pages, frames in a filmstrip, film sequence, etc.)
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3. What do you feel might be the effect on a student using this material?

______________________________________________________________________
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______________________________________________________________________           
4. For what age group would you recommend this material?

______________________________________________________________________
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______________________________________________________________________          
5. Is there anything good in this material? Please comment.

______________________________________________________________________
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6. What is your recommendation concerning this material?

______________________________________________________________________
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______________________________________________________________________           
7. Would you care to recommend other school library material on the same subject and format that would be more appropriate for this age level?

______________________________________________________________________
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