Election Transparency Initiative

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
*Name
*Phone
*Email
DESCRIPTION OF THE INCIDENT
Date of incident
Time of incident
Were the police notified?	..select.. Yes No
Address or location of the incident
City/Town/County
State	..select.. Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Narrative description of the incident

PARTIES INVOLVED IN THE INCIDENT
Name		Phone
Role		Email
Name		Phone
Role		Email
Name		Phone
Role		Email
Name		Phone
Role		Email
Additional Involved Party Comments

WITNESSES
Name of Witness		Phone
Role of Witness		Email
Name of Witness		Phone
Role of Witness		Email
Name of Witness		Phone
Role of Witness		Email
Name of Witness		Phone
Role of Witness		Email
Additional Witness Comments

ELECTRONIC EVIDENCE
Is there electronic evidence of the incident?	..select.. Yes No
What type of evidence is it?	..select.. Photo Video Audio CCTV Other
Is the evidence in your possession?	..select.. Yes No
If not in your possession, who has the evidence?
Upload evidence here. You can upload a total of three files. If you have additional evidence, please indicate that below.
First file
Second file
Third file
Do you have additional electronic evidence?	..select.. Yes No