Dixon Public Library
Patron Request for Review of Library Materials Policy

PRINT MATERIALS	

Circle Type:	Hardcover	Paperback	Magazine	Pamphlet

	Author:

	Title:

	Magazine or Pamphlet name	                            Issue:	

	Date:                                                   Inclusive Pages:

	Publisher (if known)

NON-PRINT MATERIALS

Circle Type:          Recorded Book           Children's Cassette           CD           WEB LINK	

	Author:

	Title:

	WEB Address:

REQUEST SUBMITTED BY (NAME):

Address:

City:                            Zip Code:             Phone:  (      )

COMPLAINANT REPRESENTS.

Circle One:            Himself                  Herself

Organization (Name):


IF THE OBJECTION IS TO MATERIAL NOT FOUND IN A BOOK, THEN PLEASE CIRCLE THE PROPER TERMS, AS APPLICABLE, IN THE FOLLOWING QUESTIONS:

1.  What in the book, pamphlet, magazine, recorded book, or web link seems objectionable to you?  Please be specific: cite pages, give examples.  (If additional writing space is needed, then please use another sheet of paper.  You may photocopy excerpts or use computer print-outs for examples and append them to  this form.) 




2.  What effect do you think this book, pamphlet, magazine, recorded book, or WEB link might have on others and why?




3.  For what age group would you recommend this book, pamphlet, magazine, recorded book, or web link?




4.  Did you find anything of merit about the book, pamphlet, magazine, recorded book, or web link.?




5.  Did you read the entire book, pamphlet, or magazine?                               If not, what parts did you read?




6.  Did you listen to the entire recorded book?                     If not, what parts did you hear?




7.  Did you look at the entire WEB link?             If not, what parts did you view?




8.  What do you believe is the theme of this book, pamphlet, magazine, recorded book, or web link?




9.  Are you aware of the judgment of this book, magazine, pamphlet, recorded book or WEB link by any  
           literary/WEB critics?




10.  What would you like Dixon Library to do about this book, pamphlet, magazine, recorded book, or WEB link?
             CIRCLE CHOICE:

   Do not lend it to my child or let my child access this WEB link

   Withdraw it from the library's collection/Home Page

   Have the District Librarian (Professional staff) re-evaluate the book, pamphlet, magazine, recorded book, or web link 

   Other (Please explain):



11.  What book, pamphlet, magazine, recorded book, or web link would you recommend of equal literary/WEB quality to take its place?                








Signature of Complainant

Date:

Adapted from CLA Newsletter June 1970, Vol., XIII, no. 6, Special Issue
(California Library Association. Intellectual Freedom Comm. Handbook of Procedures.)

Approved by the Library Commission on 21 October 1998.

Return to the Policies Index Page.

Input and suggestions are always welcome; as well as email to: District Librarian.