Fillable Form 11.: Voting System Anomaly Reporting Form (Election Assistance Commission)

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Form 11.: Voting System Anomaly Reporting Form (Election Assistance Commission)

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File type: PDF

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OMB Control # 3265-0004
Voting System Anomaly Reporting Form
1.
2. Phone Number
3. Email
4. Reported to Manufacturer?
5. Manufacturer Name
6. Type of Voting System
7. System Model
8. Hardware & Software Versions
9.
A. Election Official:
Name, Title, Jurisdiction
NO
B. Product Description:
DRE
Optical Scan
Unit Serial Number
C. Description of Anomaly or Event:
11.
Date of Occurrence
Polling Place Name or Location
12.
Election Type
Primary
General
Special
Ballot Marking Device
10.
EAC Certification Number
Form EAC 003C
Page 1 of 2
U.S. Election Assistance Commission
For VOLUNTARY reporting of Voting System Anomalies
14.
Description of Anomaly
YES
Other
13.
Was this your first election using this system?
YES
NO
Print Form
Submit by Email
Instructions
This form provides for the reporting of voting system anomalies by election officials. This form is part of the EAC Quality
Monitoring Program. The use of this form is voluntary. Information regarding its use can be found in Section 8.7 of the
Manual.
This form is self-explanatory.
This information is required for the EAC to provide for the certification of voting systems as required by 42 U.S.C. Section
15371. This information will be used solely to administer the EAC Testing and Certification Program. This program is
voluntary, however, individuals who wish to participate must meet the requirements of the Program. This information will
be made public consistent with the requirements of the Freedom of Information Act, the Trade Secrets Act, and any other
applicable Federal law or regulation. Public reporting burden for this collection of information is estimated to average
about 82 hours for completion of this form. This estimate includes the time for reviewing the instructions, gathering
information and completing the form. Send comments regarding this burden estimate to the Testing and Certification
Program Director, Election Assistance Commission, 1335 East West Highway, Suite 4300, Silver Spring, MD 20910.
Notwithstanding any other provision of law, no person is required to respond to, nor shall any person be subject to a
penalty for failure to respond to, or comply with, a collection of information subject to the requirements of the Paperwork
Reduction Act, unless that collection of information displays a currently valid OMB Control Number.
Form EAC 003C
Page 2 of 2
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Form 11.: Voting System Anomaly Reporting Form (Election Assistance Commission)

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Completed 10 August 2020

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