November 6, 2012 Individual Voting Survey 1. CIDNY's November 6, 2012 Individual Voting Survey Question Title * 1. Poll Site Information Borough or County: Poll Site Name: Poll Site Address: Question Title * 2. 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) Question Title * 3. 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 Question Title * 4. Did the poll worker mention that you could use a Ballot Marking Device (BMD)? Yes No Don't know Question Title * 5. Was the pathway to the BMD and the area around it clear so that you could access it easily? Yes No Comment Question Title * 6. Was the poll worker able to give you adequate information so that you could use the BMD successfully? Yes No Comment Question Title * 7. Did the BMD work without problems? Yes No Comment Question Title * 8. Were you able to vote privately and independently using the BMD? Yes No Unsure Comment Question Title * 9. 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? Question Title * 10. Were you able to scan your ballot without problems? Yes No Comment Question Title * 11. 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 Question Title * 12. How would you rate your overall experience voting on November 6, 2012? Positive Neutral Negative Comment Question Title * 13. Any suggestions for making improvements for the next election? Question Title * 14. Do you have any other comments you would like to make about your voting experience on November 6th? Question Title * 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. Name: Address: Address 2: City/Town: ZIP: Email Address: Phone Number: Done