incident report form

Use separate form for each different incident (use back of form to provide more information) Joe Walsh for Congress Committee, Inc. 218 Barron Blvd. – Grayslake, IL 60030 – 847.752.8155 Fax: 847.307.7972 Email: nick@walshforcongress.com Incident Report – November 2, 2010 General Election (please email, deliver or fax no later than 2 days after you receive this) (please print) Person Reporting ___________________________ Residence Address __________________________ Phone: Day ____________ Evening ___________ Address of incident _________________________ Cellular: _____________ Pager: ______________ Email: ___________________________________ County: ________Township or Ward __________ Precinct #_______Time of incident _______am/pm Did the Election Judges ALWAYS check the list of early and absentee voters before issuing a ballot? ___ If not, did they do so after somebody reminded them? ____ Explain below or on reverse side. Describe incident ___________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ Resolution of incident _______________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ Offender __________________________________ Role in pollingplace _________________________ Residence Address __________________________ Day Phone ___________________ Evening Phone ________________ Offender _________________________________ Role in pollingplace _________________________ Residence Address __________________________ Day Phone ___________________ Evening Phone ________________ Voter Involved _____________________________ Residence Address __________________________ Day Phone ___________________ Evening Phone ________________ Voter Involved _____________________________ Residence Address __________________________ Day Phone ___________________ Evening Phone ________________ Voter Involved _____________________________ Residence Address __________________________ Day Phone ___________________ Evening Phone ________________ Witness ___________________________________ Residence Address __________________________ Day Phone ___________________ Evening Phone ________________ Witness ___________________________________ Residence Address __________________________ Day Phone ___________________ Evening Phone ________________