* 1. Title of book

* 2. Author

* 3. Format

* 4. Your full name

* 5. Library card number

* 6. At what email address would you like to be contacted?

* 7. What is the street address where you currently live?

* 8. What city do you currently live in?

* 9. Looking at the work as a whole, what did you find unsuitable?

* 10. Did you read or listen to the entire work?

* 11. What action would you recommend be taken regarding the use of this material?

* 12. Please initial that you agree with the answers as provided.

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