Appendix C:
Sample Forms

Educational Materials Review Forms

Source: Office for Substance Abuse Prevention, ADAMHA

Accession No.:________________


Title of Product______________________________________
Other Sponsors/Endorsers_______________________________
Publication Date______________________________________
Phone ______________________________________________


_ Fact Sheet
_ Brochure
_ Booklet
_ Book
_ Poster
_ Print Ad
_ 3/4" Video
_ VHS Video
_ 16mm Film
_ Slides
_ Audiotape
_ Script
_ Information Package
_ Software
_ Other (describe):
_ Magazine
_ Article
_ Performance
_ Taped Message
_ Newsletter
_ Contest
_ Workbook
_ Curriculum
_ Classroom Material
_ Comic Book

Context(s): (check all that apply)

_ Part of a Program (describe):
_ With Other Materials
_ Stands Alone
_ Has Training Component (please enclose)

Topic(s): (check all that apply)

_ Alcohol
_ Drugs
_ Drug (specify)
_ Both Alcohol and Drugs
_ Awareness
_ Prevention
_ Intervention
_ Treatment
_ General Health/Safety
_ Other (describe)

Mode(s) of Delivery: (check all that apply)

_ Individual
_ Group
_ Instructor-Led
_ Mass Media
_ Self-Instructional

Setting(s): (check all that apply)

_ Home
_ School
_ Community
_ Health/Mental Health Care
_ Worksite
_ Justice System
_ Social Services System
_ Mass Media
_ Other (describe):

Target Audience(s): (check all that apply)

_ General Public
_ Parents (specify age of child)
_ Blacks
_ Hispanics
_ Native Americans
_ Asian and Pacific Islanders
_ Health Care Providers (specify specialty)
_ High-Risk Families/Youth
_ Policy Makers/Administrators
_ Youth (specify ages)
_ Young Adults (18-25 years)
_ Educators (specify grade[s])
_ A/D Treatment Professionals
_ A/D Prevention Professionals
_ Employers
_ Scientists and Researchers
_ Other (describe):

Language(s): (check all that apply)

_ English
_ Spanish
_ Bilingual (specify)____________
_ Other (indicate)______________


_ Low Literacy (grade level 3-5)
_ Very Easy (grade level 6-7)
_ Easy (8)
_ Average (9-10)
_ Fairly Difficult (11-13)
_ Difficult (14-16)
_ N/A


_ Yes
_ Unknown
_ No
(If yes, describe and include copy of report if possible)

Current Scope:

_ National:_______________________________
_ Regional:_______________________________
_ State:__________________________________
_ Local:__________________________________


_ Unknown
_ Restrictions on Use:
_ Permission Required to Reproduce
_ Citation Required
_ Available Free
_ Negatives Available on Loan
_ Payment Required
_ Price $
_ Available Through Free A-V Loan Program
Source (if different from above)__________________

Description: (Please describe the product in two to three sentences.)




Acc No. ________________
Date ___________________
Reviewer _______________

Target Audience (if different from Screening Form):

Topic (if different from Screening Form)

Major Messages (list):

Persuasive Technique (describe):

Distinguishing Qualities (describe):

Rate the following on a scale from "5" excellent to "1" poor:

Production Quality: ___________________________________

Content: ____________________________________________

Credibility: _________________________________________

Ability to Attract Attention:_____________________________

Ability to Convey Information:__________________________

Ability to Change Attitudes:____________________________

Ability to Elicit Appropriate Action:______________________

Appropriate for National Distribution:____________________

Overall Rating: (specify any particular strengths/weaknesses)


Recommend for further consideration (e.g., promotion, replication, purchase, adaptation, testing or evaluation)?

Please explain recommendation:

Return to:

Considerations for Field Review

Target audience-- What audience is the material best suited for? For whom should it not be used? Consider the language style, use of terminology, length, appropriateness of examples, and format in determining the target audience.

Persuasive technique-- Are the messages positive and upbeat? Are positive role models used? Fear appeals? Authority figures (who)? Peer pressure?

3. Distinguishing qualities-- Innovative or unique presentation, format or style? Fills a need for specific audience or message?

4. Production qualities
-- Is the material professional in appearance, attractive, well-written? Is the production format appropriate for the intended use (e.g., setting, equipment required)? Should production changes be considered (e.g., use of less or more color)?

5. Content-- Clear and accurate? Up to date? Appropriate message, tone, and appeal? Stimulating? New knowledge? Perpetuate myths or stereotypes? Balanced and credible? Biased or judgmental?

6. Elicit action-- Describes desired behavior? Illustrates skills required? Demonstrates appropriate behavior?

7. Credibility-- Is production or distribution source credible for target audience? For intermediaries (e.g., teachers or parents)? Is message, theme, presentation credible?

8. Appropriate for national distribution-- Will materials stand alone, or require training for use? Inappropriate for some audiences (e.g., culturally inappropriate) or geographic areas?

9. Recommendation for evaluation-- Are there questions or uncertainties that need to be resolved before determining disposition? Should materials be tested?

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