EAC-ESTEP-001C ESTEP Anomaly Reporting Form v0.1 Fillable

U.S. Election Assistance Commission

Election-Supporting Technology
Anomaly Reporting Form

OMB Control # XXXX-XXXX
Expires: XX/XX/XXXX

1. Reporter Information
Reporter Classification:

Election Official

Name:
(Last, First)
Position/Title:
Organization Name:
Phone Number:

(

-

)

Email:

2. Anomaly Statistics
Reported to Developer/
Manufacturer?

Yes

No

Date of Anomaly:
(MM/DD/YYYY)
Jurisdiction of Anomaly:
(City/County, State)
Election Type:
Was this your first election
using this system?

Primary

General

Special

Yes

No

N/A

3. Product Description
System Classification:

Electronic
Poll Book

Electronic Ballot
Delivery System

Election Night
Reporting System

Voter Registration
Portal/Database

Other (Describe):
Full System Name,
Model, and Version:
Unit Serial Number
(if applicable):
Form EAC XXXX

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4. Description of Anomaly
Issue:

Root Cause
(If Known):

Resolution
or
Corrective
Actions
(If Known):

Form EAC XXXX

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Instructions
This form provides for the reporting of election supporting technology anomalies by election officials or
manufacturers. This form is part of the EAC’s Election Supporting Technology Evaluation Program’s Quality
Monitoring Program. The use of this form is voluntary for Election Officials, and mandatory for Election Supporting
Technology Developers/Manufacturers. Information regarding its use can be found in the Election Supporting
Technology Evaluation Program Manual.
This form is self-explanatory. Please direct any questions to [email protected].
This information will be used solely to administer the EAC Election Supporting Technology Evaluation 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 2 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
Election Supporting Technology Evaluation Program Director, U.S. Election Assistance Commission, 633 3rd Street
N.W., 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 XXXX

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