REQUEST FOR RECONSIDERATION OF LIBRARY MATERIALS

STATEMENT OF CONCERN

 Date:

Name:

Address:

Phone:

Type of Resource:

___ Book___ Magazine___Newspaper          ___ Audio___Video/DVD___Display ___ Other

Did you receive a copy of theLibrary’s policy about this resource?  Y  N

Have you read, heard or seen the entire content of the resource about which

you are filling out this form?  Y  N

The specific resource you are commenting on?

Your comments:

Staff member who received the statement of concern:

Libraryreceiving statement of concern:    Eureka    Troy   Libby

Revised 8/06

Reviewed 6/12