[This is where you identify who in your own structure, has authorized use of this form—Director, Board of Trustees, Board of Education, etc.—and to whom to return the form.]
Example: The school board of Mainstream County, U.S.A., has delegated the responsibility for selection and evaluation of library/educational resources to the school library media specialist/curriculum committee, and has established reconsideration procedures to address concerns about those resources. Completion of this form is the first step in those procedures. If you wish to request reconsideration of school or library resources, please return the completed form to the Coordinator of Library Media Resources, Mainstream School Dist., 1 Mainstream
Plaza, Anytown, U.S.A.
Do you represent self? ____ Organization? ____
- Resource on which you are commenting:
____ Book ____ Textbook ____ Video ____ Display ____ Magazine ____ Library Program
____ Audio Recording ____ Newspaper ____ Electronic information/network (please specify)
____ Other __________________________
- What brought this resource to your attention?
- Have you examined the entire resource?
- What concerns you about the resource? (use other side or additional pages if necessary)
Are there resource(s) you suggest to provide additional information and/or other viewpoints on this topic?
Revised by the American Library Association Intellectual Freedom Committee
June 27, 1995