Incident report form (polls)

Riding*

Primary Contact

Name*

First Last

Phone*

Email*

What is the nature of the incident?*

Description of the incident/issue (please include as much detail as possible about what you observed, and what your concerns are)*

Any relevant attachments (e.g. photos):

Drop files here or

Poll Number (if known):

Date of incident

Time of incident

: HH

MM

DRO name and number (if applicable)

RO name and number (if applicable)

Any steps that have been taken so far in attempt to resolve the issue

Poll description (e.g. poll type (such as school or church), nearest major intersection, if known):

Name (Witness #1)

First Last

Email (Witness #1)

Phone (Witness #1)

Name (Witness #2)

First Last

Email (Witness #2)

Phone (Witness #2)

Name (Witness #3)

First Last

Email (Witness #3)

Phone (Witness #3)

Phone

This field is for validation purposes and should be left unchanged.