Your Email Address(you will receive a copy of this form): Title (exactly as appears on application): Adult Juror's name: Facilitator's name (if different): Date of Screening (MM/DD/YY): (use numbers only please, no letters) Children's age range: # of boys: (numbers only please) # of girls: (numbers only please) Cultural Make-up : Rate each question: Select from the popup menu the number that best matches each question 5 = Great; 4 = Good; 3 = Good, but...; 2 = OK; 1 = Not So Good; 0 = Terrible; N/A = Not Applicable APPEAL 1. How well did you like the video? Explain? -Select One- 5 - Great 4 - Good 3 - Good, but... 2 - O K 1 - Not So Good 0 - Terrible N/A - Not Applicable 2. Would you enjoy watching this video again? Why? -Select One- 5 - Great 4 - Good 3 - Good, but... 2 - O K 1 - Not So Good 0 - Terrible N/A - Not Applicable CONTENT 3. How well did you understand the story? Did it make you think about people or things you know? Explain. -Select One- 5 - Great 4 - Good 3 - Good, but... 2 - O K 1 - Not So Good 0 - Terrible N/A - Not Applicable 4. Is the story accurate or believable? Explain. -Select One- 5 - Great 4 - Good 3 - Good, but... 2 - O K 1 - Not So Good 0 - Terrible N/A - Not Applicable 5. If role models are used, are they positive? Are social interactions respectful of race, culture and gender? Explain. -Select One- 5 - Great 4 - Good 3 - Good, but... 2 - O K 1 - Not So Good 0 - Terrible N/A - Not Applicable 6. Is it respectful of persons your age? Explain. -Select One- 5 - Great 4 - Good 3 - Good, but... 2 - O K 1 - Not So Good 0 - Terrible N/A - Not Applicable PRODUCTION QUALITY 7. How well did you like the technical presentation? Describe. -Select One- 5 - Great 4 - Good 3 - Good, but... 2 - O K 1 - Not So Good 0 - Terrible N/A - Not Applicable 8. How would you rate it in terms of originality, creativity, visual appeal? Tell me more. -Select One- 5 - Great 4 - Good 3 - Good, but... 2 - O K 1 - Not So Good 0 - Terrible N/A - Not Applicable BENEFITS 9. How much did this video motivate you to learn more about what you saw? -Select One- 5 - Great 4 - Good 3 - Good, but... 2 - O K 1 - Not So Good 0 - Terrible N/A - Not Applicable 10. What was your favorite part? Please total the points for questions 1 through 10: This program was  :  Great!  I'd watch it again  OK, I liked some of it  Boring  Too fast/too slow  Doesn't appeal to everyone  The stereotypes are negative  Nobody liked it FINAL RATING:   NO   QUALIFIED YES   YES   ALL-STAR  Contains gratuitous sex or violence  Has a condescending attitude towards children  Contains physical or verbal abuse  Contains racial, gender, cultural or religious bias  Models unsafe behavior Indicate if you've given it a QY for one of the following reasons or explain other reasons.  Pace inappropriate, too slow/fast  Stereotypical behavior prominent  Lacking in cultural diversity  Appealing to special audience This title meets or exceeds the baseline criteria: No gratuitous sex or violence No racial, gender, culture or religion bias No unsafe behavior No condescension towards children No verbal or physical abuse What are the specific attributes? (use all-star check list): Tell us why you gave the final rating above: When you are finished, please click the submit button below :