Name of individual initiating request:_________________________________________

Address: ____________________________________________________________

City__________________ State_____ Zip Code ________Telephone_____________

Title________________________________________________________________

Author/Presentor_______________________________________________________

Format: Book ___ Video____ Spoken Word____ CD-ROM____ Misc.________

1. What exactly do you object to in this material?
   (Please be specific, i.e. cite pages where possible. Use back of form if necessary.)

   ____________________________________________________________________

   ____________________________________________________________________

   ____________________________________________________________________

2. For what age group would you recommend this material?

____________________________________________________________________

3. Did you read or view the entire work?________ If not, what parts did you read or view?

   ____________________________________________________________________

4. In your opinion, is there anything of value in this material?

   ____________________________________________________________________

   ____________________________________________________________________

5. Is there another title you would recommend in place of this one?

____________________________________________________________________

6. Do you have any additional comments you would like to make about this material?

____________________________________________________________________

Date______________ Signature__________________________________________

Thank you for your comments. This request will be reviewed by the Library’s Selection Review Committee. You should receive a response within four weeks.

The decision of the Selection Review Committee may be appealed by writing to the Norfolk Public Library Board of Trustees in care of the Director of Libraries. The Board will consider an appeal at their next regularly scheduled Board meeting to which both the patron and representatives from the Selection Review Committee will be invited to share their views and concerns. The decision of the Board will be final.
NPL 12/99