
{if isset($confirm_send)}
<div class="confirm_send">{$confirm_send}</div>
{/if}

<form action="{$smarty.const._URL}/report.php?vid={$vid}&do={$do}" method="post">
<table width="100%" border="0" cellspacing="2" cellpadding="2">
  <tr>
    <td width="170"><strong>{$lang.your_name}</strong>: </td>
    <td><input name="name" type="text" class="inputtext" size="20" maxlength="50" value="{if $logged_in}{$s_name}{else}{$post_name}{/if}" /></td>
  </tr>
  <tr>
    <td><strong>{$lang.your_email}</strong>: </td>
    <td><input name="email" type="text" class="inputtext" size="20" maxlength="50" value="{if $logged_in}{$s_name}{else}{$post_email}{/if}" /> <div class="error_msg">{$err_email}</div></td>
  </tr>
  <tr>
    <td><strong>Specify problem</strong>: </td>
    <td>
        <select name="reason" class="inputtext">
		<option value="{$post_reason}" selected="selected">{$post_reason}</option>
		<option value=""></option>
		<option value="Not working">Not working</option>
		<option value="Wrong video">Wrong video</option>
		<option value="Racist or hate content">Racist or hate content</option>
		<option value="Copyrighted Content">Copyrighted Content</option>
        </select>
    </td>
  </tr>
  <tr>
    <td><div class="error_msg">{$err_captcha}</div></td>
    <td>
		
	<img src="{$smarty.const._URL}/include/securimage_show.php?sid={php} echo md5(uniqid(time())); {/php}" id="image" align="absmiddle" />
	<a href="#" onclick="document.getElementById('image').src = '{$smarty.const._URL}/include/securimage_show.php?sid=' + Math.random(); return false"><img src="{$smarty.const._URL}/templates/{$template_dir}/images/reload.gif" border="0" align="absmiddle" /></a>
		
    </td>
  </tr>
  <tr>
    <td><strong>Confirm submission</strong> </td>
    <td><input type="text" name="imagetext" maxlength=10 autocomplete="off" class="inputtext" /></td>
  </tr>
  <tr>
    <td>&nbsp;</td>
    <td><label>
      <input type="submit" name="Submit" value="Send report" class="inputbutton" />
    </label></td>
  </tr>
</table>
</form>
