1. Have you read/heard/seen the material in its entirety?_______________________

2. To what do you specifically object? Please cite specific passages, pages, etc.____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

3. Is your objection to this material based upon your personal exposure to it, upon reports you have heard, or both?________________________________________ ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

4. What do you believe is the theme or purpose of the material?_________________ ____________________________________________________________________________________________________________________________________ __________________________________________________________________

(over, please)

5. What do you feel might be the result of reading/viewing this work?_________________________________________________________________________________________________________________________________________________________________________________________________

6. In its place, what work of equal value would you recommend that would convey as valuable a picture and perspective of a society or a set of values?________________________________________________________________________________________________________________________________________________________________________________________________

7. Do you wish to make an oral presentation of 15 minutes or less to the Material Review Committee?___________

Signature Date