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Voting System Testing & Certification

Manuals and Forms

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Anomaly Reporting Form

OMB Control #3265-0004
Form EAC 003C

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.

Anomaly Reporting Form

indicates required field

A. Election Official

1.

Name, Title, Jurisdiction:

2.

Phone Number:

3.

Email:

4.

Reported to Manufacturer?

YesNo

B. Product Description

5.

Manufacturer Name:

6.

Type of Voting System:

Ballot Marking DeviceDREOptical ScanOther

7.

System Model:

8.

Hardware & Software Versions:

9.

Unit Serial Number:

10.

EAC Certification Number:

C. Description of Anomaly or Event

11.

Date of Occurrence:

12.

Polling Place Name or Locaction:

13.

Election Type:

GeneralPrimarySpecial

14.

Was this your first election using this system?

YesNo

15.

Description of Anomaly:

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, 1201 New York Avenue, NW, Suite 300, Washington, DC 20005. Not withstanding any other provision of law, no person is required to respond to, nor shall any person be subject to apenalty 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.