Westchester 2017 Voter Protection: NYDLC Incident Report
Poll watchers and Boiler Room attorneys should use this form to "Shift Check In" and to report Election Day (11/7/2017) incidents, including those that are resolved on site without escalation to the Boiler room. When reporting an issue, please be as detailed as possible (include name and title of poll workers involved and any voters personally affected).

Please complete a separate Incident Report for each distinct issue, even if they arise contemporaneously at the same poll site. For urgent matters on Election Day, call your Boiler Room contact (at # provided with your Election Day assignment).

Name of Poll Watcher *
Your answer
Poll Watcher's Mobile # *
Your answer
County where poll site is located *
Election Day Incident Report
Name of poll site (use name given in your Election Day assignment) *
Your answer
ADs/EDs affected? (optional)
Your answer
Type of incident *
Scope of Issue? *
Brief description of incident (who, what, where, when, please be specific. Just the facts) *
Your answer
Follow up required? *
Time of Incident (include time issue arose & time resolved, if closed) *
Your answer
Voter Information (if applicable)
If incident affected specific voters, please follow up and complete this section with as much identifying information as they are willing to provide. More information will better enable us to document/resolve the incident.
Voter 1: Full Name (as appears on registration), mobile #, Email, full DOB, zip code, demographics
Your answer
Voter 2: Full Name (as appears on registration), mobile #, Email, full DOB, zip code, demographics
Your answer
Voter 3: Full Name (as appears on registration), mobile #, Email, full DOB, zip code, demographics
Your answer
Affected Voter Demographics (optional)
This section is used to aggregate incidents and identify patterns so we can better evaluate scale/scope and whether it is targeted or systemic. If applicable, explain context:
Are affected voters part of identifiable class/ targeted as member of group (eg: race/religion, student, disabled, elderly, gender, LGBTQ)?
Your answer
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