Harris County Democratic Party

Election Incident Report Form

2010 Primary Election

Caller’s name

Caller’s phone number

Caller’s address

Caller’s e-mail

Precinct / poll location Date incident

at which incident occurred
occurred

If the incident involved a voter, obtain the voter’s name and address from election officials:

Voter's name

Voter's address

Please describe the

incident. Be as specific
as possible.
Use 2nd page or back of
page if more space is
needed.

If voter, were you able to cast

Yes No Cast a provisional ballot? Yes No
your ballot?

Other persons with knowledge of the incident:

Name Phone number

Name Phone number

Name Phone number

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Date reported to
Report taken by
HCDP

Action taken

Outcome

Return completed form to:

HCDP Email to martha@hcdp.org
1445 North Loop West, Suite 110 Fax: 713-802-2082
Houston, TX 77008 Call 713-802-0085 for more information