Disability Complaint Form

* Last Name

* First Name

M.I.

* Address

* City

* State

* Zip Code

* Email

* Phone Number

* This is being filled out by

* Election

* Poll Location

* Date of visit to the Poll

* What challenges or discrimination did you encounter voting at the above referenced polling location?

* Please describe these challenges or issues in more detail:
(Characters: 0/2000)

Please list the names and contact information (phone number, e-mail address, etc.) of any witnesses. If applicable, please also include their relationship to you.
(Characters: 0/2000)

Did you speak to any election judges, poll workers, or employees at the poll about the challenges you encountered? If so, please list their name(s) if you know it (them).
(Characters: 0/2000)

What, if any, accommodations were made to address the challenges you encountered at the polling location?
(Characters: 0/2000)

What accommodation or changes would you suggest be made at this polling location?
(Characters: 0/2000)

Do you have any other comments or suggestions related to your voting experience?
(Characters: 0/2000)