Appendix A
LIBRARY MATERIALS REVIEW REQUEST FORM - DUCHESNE COUNTY SCHOOL DISTRICT
Title of the book/material: Author: Name of person requesting the review: Telephone: Address: City: Zip: Email: 1) Name of the school where the book/material is housed:
2) What is your affiliation with the school?
3) Are you asking the committee to remove the book/material?
4) Have you personally read (or viewed) the entire book (or media)?
5) What concerns you about this book/material? (Please provide examples, page numbers, links, or any other information to help in locating or identifying content of concern. Please attach additional pages as needed and any images or other corroborating evidence.)
Signature:
Date:
* Please deliver this form to the school principal or the district office.
Made with FlippingBook flipbook maker