Incident Report Form

Instructions: Please fill in the form as completely as possible as soon as possible after (or during) the incident. Take the time to collect names and contact details of other witnesses. If you collect electronic evidence (picture, video or audio recording), you can attach the file(s) and submit with your report, but retain the original on your phone or other electronic device.

In writing the narrative description of the incident (what happened, how it happened, etc.), be as specific as possible. Include names and/or titles of the individuals involved in the incident, if possible. If the incident occurred in a voting place or at a drop box location, you have the right to request the names and titles of those working in the facility.

REPORTER INFORMATION

First Name*

Last Name*

Telephone Number*

Email*

DESCRIPTION OF THE INCIDENT

Date of incident

Time of incident

Were the police notified?

Yes No

Address

Address 2

City

State

Zip

County

Name of polling station

Narrative description of the incident

PARTIES INVOLVED IN THE INCIDENT

Party 1

Full Name

Role in the Incident

Telephone Number

Party 2

Full Name

Role in the Incident

Telephone Number

Party 3

Full Name

Role in the Incident

Telephone Number

Party 4

Full Name

Role in the Incident

Telephone Number

Additional Involved Party Comments

WITNESSES

Witness 1

Full Name

Role in the Incident

Telephone Number

Witness 2

Full Name

Role in the Incident

Telephone Number

Witness 3

Full Name

Role in the Incident

Telephone Number

Witness 4

Full Name

Role in the Incident

Telephone Number

Additional Witness Comments

ELECTRONIC EVIDENCE

Is there electronic evidence of the incident?

Yes No

What type of evidence is it?

Is the evidence in your possession?

Yes No

If not in your possession, who has the evidence?

Notes

Upload evidence here

If you have additional evidence, please indicate that below.

First file

Second file

Third file

Do you have additional electronic evidence?

Yes No