Adopted October 2003

Please print a copy of this form, complete it and submit it to the Head Librarian.

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Date

Item or Material:

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Title

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Author/Producer

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Type of Material (book, periodical, dvd, cd, electronic resource, etc.)

Request initiated by:_______________________________________________

Phone________________________ E-mail:_____________________________

Relationship to The Bush School:____________________________________

The following questions are to be answered after having read, listened to or viewed the material in its entirety. If additional space is required to answer questions, please attach additional sheets, including information that identifies the question, the material and your name.

1. Have you read/viewed/listened to this material in its entirety?____________

2. What do you find objectionable about this item? Please be specific in citing pages or other location information (URL, title of article, etc.)

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3. What do you feel might be the harmful effects of this material on the reader/viewer/listener?

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4. For what age group do you consider this item to be appropriate?_____________

5. Are there redeeming qualities about this item?_____ Please comment.

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6. Would you like to recommend an item of the same subject and format that could replace this one?

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Signature of Complainant

Received by Head Librarian

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Signature of Head Librarian & Date

Received by Head of School___________________________________________
Date

Review Committee Convened__________________________________________
Date

Members of Review Committee:________________________________________

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Meeting with Complainant:____________________________________________
Date

Disposition:________________________________________________________

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Communicated to Complainant_________________________________________
Date

Response of Complainant:____________________________________________

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