Media Feedback Request Form
Please provide your feedback to help us improve our media content. Your input is valuable and will remain confidential.
Your Full Name
First Name
Last Name
Email Address
example@example.com
Which type of media did you review?
*
Please Select
Video
Article
Podcast/Audio
Image/Infographic
Other
Title or Name of the Media Piece
*
Where did you access this media?
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Please Select
Website
Social Media
Email Newsletter
Streaming Platform
Other
When did you view or listen to the media?
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
How would you rate the overall quality of the media?
*
1
2
3
4
5
Please rate the following aspects of the media:
*
Rows
Clarity
Engagement
Relevance
Length/Duration
Poor
1
2
3
4
Fair
5
6
7
8
Good
9
10
11
12
Very Good
13
14
15
16
Excellent
17
18
19
20
Did you experience any technical issues with the media?
No issues
Yes, audio problems
Yes, video/display issues
Yes, loading/buffering issues
Other
How likely are you to recommend this media to others?
*
Not likely
1
2
3
4
5
6
7
8
9
Very likely
10
1 is Not likely, 10 is Very likely
What did you like most about this media?
What could be improved in this media?
Please select your age group
Please Select
Under 18
18-24
25-34
35-44
45-54
55-64
65 or older
Prefer not to say
Occupation (optional)
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