Challenged Materials Censorship Form: Intellectual Freedom Committee
Object of Challenge:
Date of Challenge:
Title:
Copyright/Issue Date:
Author/Performer(s):
Publisher/Producer:
Print Material: Print Textbook Magazine Newspaper Pamphlet Play Student Publication
Nonprint Material: Artwork Photo Sound Recording Video/DVD Audiobook
Other: Collection Exhibit Performance Speech Website Other
Grounds for Challenge (Check as many as apply)
1. Cultural
Anti-Ethnic Insensitivity Racism Sexism Inaccuracy
2. Sexual
Homosexuality Nudity Sex Education Sexually Explicit Unsuited to Age Group
3. Values
Anti-Family Offensive Language Political Viewpoint Religious Viewpoint Violence
4. Social Issues
Abortion Drugs Occult/Satanism Suicide
5. Other Reasons (specify):
Initiator of Challenge
Individual:
Administrator Board Member Clergy Parent Teacher Patron Staff Elected Official
Group:
Government Special Interest Group Religious Group Other:

Organizations Supporting Challenge:

Institution Being Challenged

(This information will be kept confidential)

Name:
Phone:
Address:
City:
Zip Code:
Email:
School Related: School School Library Grade Level(s) Affected:
Other Library: Academic Library Public Library Prison Special Library
Other:
Person Reporting This Challenge

(This information will be kept confidential)

Name:
Title:
Address (if different from above):
City:
Zip Code:
Phone:
Outcome of Challenge

Would you be willing to share your experience with another librarian in a similar situation?

Yes No
Please Note: Individuals and Institutions will be kept confidential