Form 003C Voting System Anomaly Reporting Form

U.S. Election Assistance Commission
OMB Control # XXXX-XXXX

Voting System Anomaly Reporting Form

The reporting of voting system anomalies is required by voting system
manufacturers and voluntary for election officials.
1. Reporter Information.
Reporter is Select One
Name and Position:
Jurisdiction or Manufacturer name:
Phone:

E-mail:

Anomaly Reported to Manufacturer?

YES

NO

Date of Anomaly Occurrence:
Place of Anomaly Occurrence:
Election Type:

Primary

Special

General

Was this your first election using this system?

YES

NO

N/A

2. Product Description:
Type of Voting System:

DRE

Ballot Marking Device

Central (Bulk) Scanner

Precinct Scanner

Other (Describe):

System Name / Model:
Unit Serial Number:

3. Description of Anomaly:

Form EAC 003C

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Description of Anomaly Continued:

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 for Election Officials, and mandatory for Voting
System Manufacturers. 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, 633rd Street NW , Suite 200, Washington, DC 20001 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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