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Title: _________________________________________________________________________
Author: ____________________________ Publisher: __________________________________
Media format:  Book ____ Periodical ____ Other ______________________________________
Request initiated by: ____________________________________________________________
Address: ______________________________________________________________________
City:__________________________________________ State: ________ Zip: ______________
Telephone: ____________________________________________________________________

Do you represent:
_____ Yourself?
_____ An organization (name) ____________________________________________________
_____ Other group (name) ________________________________________________________

1.         To what parts in the work do you object?    Please be specific, citing pages or parts as

2.         Which parts of the work did you review?

3.         What do you feel might be the result of reading, viewing or listening to this material?

4.         To what age group would you recommend this material?

5.         What do you believe is the theme of this material?

6.         Are you aware of any judgments or reviews of this material by literary critics?

7.         What would you like the library to do about this material?

8.         In its place, what work would you recommend that would convey as valuable a picture and perspective of the subject treated?

9.         Do you believe anyone has the right to tell you and your family what materials you should be able to read, view or listen to?  If so, why?  If not, why not?





Updated December 2010.  

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Berkshire Athenaeum, Pittsfield's Public Library, Pittsfield, Massachusetts