Voter Problem Report Form

Please enter information as precisely as possible, even impressions and information that may seem of minor importance. Every detail is extremely important, as apparently insignificant details may show an important and obvious pattern when seen thousands of times. So, please tell everything and let the researchers determine whether it is important.

For problems with your report or questions please contact us..

To ensure the validity of this report we will ask for an email address for verification. Anonymous reports will be accepted, but they will be treated with less importance.

(Please submit a separate report for each type of incident and each person.)

PUBLIC INFORMATION
Information in this first section is non-personal and will be readily available to the public
Do not include your name or other personal information here
Your personal information is not passed on to third parties or made public without your permission.
People Involved
Personal Involvment:
Number of people who had the problem?:
Were there witnesses?:
Description of Incident
What is the specific problem?
Details of Incident:
Was Problem Resolved?: Yes: No:
Are You Satisfied?: Yes: No:
Describe Resolution:
Location
* (means required field)
*Country:
*State/Province:
St/Prov (Non-US):
County:
*City:
*Precinct/Voting District:
*Location of Incident:
Date and Time
Date (mm/dd/yy):
Time (hour:min):
Time Period
Reporting of Problem
Did you report problem?: Yes: No:
First Report Made to:
More Details:
Did You Get a Response?: Yes: No:
Details of Response:

Did Response resolve Problem?: Yes: No:
Why or why not:

Did you make a second report?: Yes: No:

Second Report Made to:
More Details:
Did You Get a Response?: Yes: No:
Details of Response:

Did Response resolve Problem?: Yes: No:
Why or why not:

Did you make a third report?: Yes: No:
Third Report Made to:
More Details:
Did You Get a Response?: Yes: No:
Details of Response:

Did Response resolve Problem?: Yes: No:
Why or why not:

Witnesses
List witnesses and whether they can be contacted. If you don't know them, give the best description you can.

Witness 1: Contact?:Yes: No:
Contact Information:
Witness 2: Contact?:Yes: No:
Contact Information:
Witness 3: Contact?:Yes: No:
Contact Information:
Witness 4: Contact?:Yes: No:
Contact Information:

PERSONAL INFORMATION
Information in this section is personal.
It VERY important that you can be contacted to verify your report. Anonymous reports are of much less value.
No information that can identify you will be made public without your consent.
Person Involved in Incident
First Name:
Last Name:
Address:
Address 2:
*Zip/Postal Code:
Email:
Telephone: - Ext.
May we contact you?: Yes: No:
Would you be willing to speak to the press?: Yes: No:
Would you be willing to speak to investigators?: Yes: No:
Person Filing Report (if different)
First Name:
Last Name:
Address:
Address 2:
*Zip/Postal Code:
Email:
Telephone: - Ext.
May we contact you?: Yes: No:
Would you be willing to speak to the press?: Yes: No:
Would you be willing to speak to investigators?: Yes: No:

SURVEY
How did you find out about this site?:
What is the specific source?
Questions or comments:
Suggestions: