Form EAC 003C EAC 003C Anomaly Reporting Form

U.S. Election Assistance Commission

Print Form

Submit by Email
OMB Control # 3265-0004

Voting System Anomaly Reporting Form
For VOLUNTARY reporting of Voting System Anomalies

A. Election Official:

1.

C. Description of Anomaly or Event:

Name, Title, Jurisdiction

11.

Date of Occurrence

12.

Election Type
Primary

13.
2.

Phone Number

3.

Email

4.

General

Special

Was this your first election using this system?
YES

14.

Polling Place Name or Location

NO

Description of Anomaly

Reported to Manufacturer?
YES

NO

B. Product Description:

5.

Manufacturer Name

6.

Type of Voting System
DRE

Ballot Marking Device

Optical Scan

Other

7.

System Model

8.

Hardware & Software Versions

9.

Unit Serial Number

10.

EAC Certification Number

Form EAC 003C

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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, 1225 New York Avenue, N.W., Suite 1100, Washington, DC 20005.
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

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