November 6, 2012 Individual Voting Survey
Thank You
1. CIDNY's November 6, 2012 Individual Voting Survey
1
. Poll Site Information
Poll Site Information
Borough or County:
Poll Site Name:
Poll Site Address:
2
. If you have a Disability, please check all that apply: (OPTIONAL - used for demographic statistics only)
If you have a Disability, please check all that apply: (OPTIONAL - used for demographic statistics only)
Physical
Hearing
Visual
Cognitive
Mental Health
Other (please specify)
3
. How did you mark your ballot on November 6th?
How did you mark your ballot on November 6th?
With a BMD
By Hand - please explain why in the comment field below and skip to Question #10
4
. Did the poll worker mention that you could use a Ballot Marking Device (BMD)?
Did the poll worker mention that you could use a Ballot Marking Device (BMD)?
Yes
No
Don't know
5
. Was the pathway to the BMD and the area around it clear so that you could access it easily?
Was the pathway to the BMD and the area around it clear so that you could access it easily?
Yes
No
Comment
6
. Was the poll worker able to give you adequate information so that you could use the BMD successfully?
Was the poll worker able to give you adequate information so that you could use the BMD successfully?
Yes
No
Comment
7
. Did the BMD work without problems?
Did the BMD work without problems?
Yes
No
Comment
8
. Were you able to vote privately and independently using the BMD?
Were you able to vote privately and independently using the BMD?
Yes
No
Unsure
Comment
9
. Were you able to vote within what you believe is a reasonable amount of time with the BMD?
Were you able to vote within what you believe is a reasonable amount of time with the BMD?
Yes
No
How long did it take to vote?
10
. Were you able to scan your ballot without problems?
Were you able to scan your ballot without problems?
Yes
No
Comment
11
. Did you experience any of the following when you voted? (Check all that apply)
Did you experience any of the following when you voted? (Check all that apply)
Confusing or missing signs outside the poll site
Hard to find accessible entrance
Locked doors at accessible entrance
Doors that were hard to open
Doors/paths that were too narrow
Problem Ramps
Confusing path to voting
Long path to voting
Items blocking access to accessible entrance
Items blocking access in voting area
12
. How would you rate your overall experience voting on November 6, 2012?
How would you rate your overall experience voting on November 6, 2012?
Positive
Neutral
Negative
Comment
13
. Any suggestions for making improvements for the next election?
Any suggestions for making improvements for the next election?
14
. Do you have any other comments you would like to make about your voting experience on November 6th?
Do you have any other comments you would like to make about your voting experience on November 6th?
15
. Optional: Your information will be kept confidential. In order to present a report of findings to the Board of Elections, we may want to contact you for further information about your voting experience.
Optional: Your information will be kept confidential. In order to present a report of findings to the Board of Elections, we may want to contact you for further information about your voting experience.
Name:
Address:
Address 2:
City/Town:
ZIP:
Email Address:
Phone Number:
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