POSTELECTIONFEEDBACKFORMINDIANSWITH

DISABILITIES
Compliments?Complaints?Concerns?WhateveryourvotingexperienceasanIndiancitizenwith
disability,pkeaseshareyourfeedback.Onlyanonymiseddatawillbefreeandopentoallstakeholdersfor
qualityanalysisandtofinetunesectoraladvocacy.DisabilityRightsAlliance(DRA)maygetintouchwith
youbeforeanonymisationincaseakeyclarificationisneededrestassuredthatyourprivacywillbe
respected.

>Thiswilltake10minutestocompleteonanycomputingdevicewithadataconnection.
>IfphotosareavailableonlineandshareableviaaURL,pleaseenterthesamein'ANYOTHER
COMMENTS'sectionboxatformend.Alternativelytheycanbesenttoemailathttp://scr.im/drai
>PleasetypeNAwherenotapplicableand/ormandatoryresponseisrequested.Otheracronymsused:
NOTA=Noneoftheabove/EVM=Electronicvotingmachine/EPIC=VoterIDnumber
>TheOTHERboxcanbeusedtotypedetailsofoptionsnotlisted

*Required

1.InformantContactdetails*
Ifyouarefillingthisonbehalfofsomeoneelseoronsomethingyou'vereadorheardpleaseselect
'Other'andenteryourmobilenumber,relationshiptovoter,name
Markonlyoneoval.

Iambothvoterandinformantcontactdetailsarethesame

Other:

VOTERDETAILS

2.EnterFullName*
(FirstNameLastName)

3.Entermobilenumber/alternatecontactnumber
*
Countrycodeor'0'beforenumberisnotrequired.
Pleaseenter10digitmobilenumberonly
4.Enteremailid*

5.Howmanytimeshaveyouvotedinthepast*
Markonlyoneoval.

Thisismyfirsttime!
Between25times
Morethan6times

6.Iuse/needthefollowinginmydailylife*
Selectwhicheveroptionsapply.Ifnotinlist(ornotapplicable),chooselastoptionlabelled'OTHER'
andelaborate(ortypeNA)
Checkallthatapply.

Manualwheelchair
Motorisedwheelchair
Crutches
Upperlimborthotic/prosthetic
Lowerlimborthotic/prosthetic
Walkingstick/tripod/walkerframe
WhiteCane/SmartCane/OtherVisuallyImpairedMobilityAids
Braille/Tactile/Audiofeedback
Lowvisionaids(Magnifiers/BlackMarkers)
Indian/RegionalSignLanguage
Kinesthetic/TadomaSignlanguage
HearingAid/Lipreading
AssistiveSpeechdevice/Simplelanguagecommunication/CommunicationChartorBoard/
AAC
Personalassistantformobility/motorormanualdexterity/communicationorlanguage
interpretation/socialimpairments/support
Calm,quiet,distractionless,stressfreespacetofunction

Other:

POLLINGSTATE&CONSTITUENCYDETAILS

7.EnterVoterID/EPICnumber(likeTPW1730365)

8.EnterthePollingStationName*
(Nameoftheschool/buildingwithfulladdress)

9.City/Town/Villagename*
10.ChooseState/UT*
Markonlyoneoval.

AndamanandNicobarIslands
AndhraPradesh
ArunachalPradesh
Assam
Bihar
Chandigarh
Chhattisgarh
DadraandNagarHaveli
DamanandDiu
Delhi
Goa
Gujarat
Haryana
HimachalPradesh
Jammu(Winter)
JammuandKashmir
Jharkhand
Karnataka
Kerala
Lakshadweep
MadhyaPradesh
Maharashtra
Manipur
Meghalaya
Mizoram
Nagaland
Odisha
Puducherry
Punjab
Rajasthan
Sikkim
TamilNadu
Telangana
Tripura
UttarPradesh
Uttarakhand
WestBengal

11.EnterDistrict*

12.ConstituencyName
PLACES&PEOPLEACCESSIBILITY&EXPERIENCE

Q&A:GETTINGTHERE

1)Selectoptionsthatapplyfromcheckboxes
2)Elaboratedetails/reasonsinADD.DETAILSboxthatfollowsortypeNAifnothingfurthertoadd

13.Ifyouareapersonfacingmobilitydifficulties,howdidyoureachthepollingstation?Select
whicheverapplies*
Checkallthatapply.

NANotapplicable,Ihavenomobilitydifficulties
Walked/Wheelchaired/Tricycled
Bus
Train/Metro
Auto/ShareAuto
Taxi/Shuttle/Carpool
Own/Borrowedvehicle

Other:
14.Difficultiesfacedingettingtopollinglocation*
Selectwhicheveroptionsapply.Ifanyother,pleasedescribe.
Checkallthatapply.

Publictransportinaccessible
Pavementwithoutslopesandtactiles
Approachpathwaynotaccessible
Lackofdirectionsignage
Zebracrossingnotavailable
Notrafficcontrol
Securityarrangements/Barricadeblocks
Alighting/Parkingproblems
NOTA!Noneoftheaboveproblemsfaced

Other:

15.ADDDETAILS:Gettingthere
Thisisamandatorybox.Elaboratedetails/reasonsfromquestion(s)aboveortypeNAifnothing
furthertoadd

Q&A:POLLINGSTATIONFACILITIES

INSTRUCTIONS:
1)Selectoptionsthatapplyfromquestion'scheckboxes
2)Elaboratedetails/reasonsinADD.DETAILSboxthatfollowsortypeNAifnothingfurthertoadd

TIPSONBASICMINIMUMFACILITIESTOBEPROVIDED=

>Informationanddirectionsignvisibilityanddisplayreadability(highcontrastpicture+locallanguage
textinlargesansseriffont,atwheelchairheight)

>Safeobstaclefreeegressmovementandturningspaceofatleast1.2mor4feetwidth(Obstacles=
Lowhangingobjectstreespolesdebrispotholessandysurfacelevelchangesetc.)

>RampWidth1to1.2m(3.5to4feet(flatantislipperysurfacegentleslopeofatleast1:10gradient
handrailsonbothsides)

>Wheelchairfriendlytablesshouldbeat675775mmheightfromfloorallowingkneespacedepthof540
600mmwithEVMequipmentoperationcontrolsnohigherthan1200mmfromground.

>EVMshouldhaveBraillenumberedstickersadjacenttobuttonswhichcanbereferredtowithBraille
candidateorderedlist.Anextensioncordof750mmshouldbeprovidedtoenableangledviewingand
selection.Excessiveforceshouldnotberequiredtopressbuttonandfeedbackshouldincludeaudio/
visual/tactilefeedback.

>AccessibleToilet:(Westernclosetwitheasilyreachablehandshowergrabbarslowhandwashdry
antislipperysurfaceamplelighting)
16.ABSENT/UNUSABLEbasicminimumfacilitiesatpollingstations*
SelectwhicheverfeatureswereNOTavailable.Ifeithernotnoticedoriffeaturepresentindicatesoin
OTHERbox.PleaseprovidemoredetailsinADD.DETAILSbox
Checkallthatapply.

Barricadefree,accessibleparkingwithboothclosetoalightingpoint
Visible,readableinformation/signageatwheelchairheight
Prominentlyindicatedpriorityvotingqueuefordisabled/elderly/pregnant
Boothwheelchairfacilitywithvolunteer
Safelevelchangeswithhandrailsand/orramp
Obstaclefreemovementandegressforvoterswhocrawl/usewheelchairsormobilityaids
Wheelchairfriendlytablesforhelpdesk,electionofficials,EVM,drinkingwater
Brailleballotpaperreference
Braillenumberedelectronicvotingmachineataccessibleheight/reach/lineofsight
Accessibletoiletforwheelchairusers/voterswhocrawl
Drinkingwaterataccessibleheight
Adequate,uniformlighting
Cleardemarcationofpotentialhazards

Other:

17.ADD.DETAILS:PollingstationsfacilitiesBasicminimum*
Thisisamandatorybox.Elaboratedetails/reasonsfromquestion(s)aboveortypeNAifnothing
furthertoadd

VOTINGPROCESS:HUMANINTERACTION/INTERFACE

Q&A:PREVOTINGACCESSTOINFORMATION/OFFICIAL
MECHANISMS

1)Selectoptionsthatapplyfromthequestion'scheckboxes
2)Elaboratedetails/reasonsinADD.DETAILSboxthatfollowsortypeNAifnothingfurthertoadd

18.Didyoureceive/experienceanyofthefollowingbeforevotingday?*
Checkallthatapply.

Voterinformation/awarenessmessageswerereceivedaccordingtomyspecificneedsvia
variouscommunicationchannels
Mockvoting,runthroughortrainingwereconductedbeforevotingdayformyfamiliarisation
Irequiredsomeone'sassistanceincheckingvotingstatus/completingregistration.Detailsin
ADD.DETAILSboxthatfollows.
NOTAReceivednoneoftheabove
19.ADD.DETAILS:PreVotingAccesstoInformation/OfficialMechanisms*
Thisisamandatorybox.Elaboratedetails/reasonsfromquestion(s)aboveortypeNAifnothing
furthertoadd

Q&A:ASSISTANCEDURINGVOTINGPROCESS

1)Selecttheoptionthatappliesfromthequestions'dropdownlist
2)Elaboratedetails/reasonsinADDDETAILSboxthatfollowsortypeNAifnothingfurthertoadd

20.Assistancetoreach/movearoundpollingbooth?*
Markonlyoneoval.

Irequiredsupportfromboothofficials/volunteersasIwasunaccompanied
Iwasaccompaniedbyasupportperson
Ididnotrequiremobility/navigationassistance

21.Successfulvotingusingtheelectronicvotingmachine*
Markonlyoneoval.

Yes:Withoutassistant
Yes:Withmypersonalassistant'ssupport
Yes:Withboothofficialassupportperson
Yes:Withforcedassistance.Referboxfordetails
No:Iwasn'tABLEtovote.Referboxfordetails
No:Iwasn'tALLOWEDtovote.Referboxfordetails

22.Priorityvotingforaccompanyingassistant*
Markonlyoneoval.

Ivotedwithoutanassistant
Yes,Mysupportpersonwasallowedtovoteimmediatelyaftermyvotingslot
No,IhadtowaitasmysupportpersonwasNOTallowedtovoteimmediatelyafterme
NAElectionofficialwasmyassistant
NAIcouldnotvote

23.TollfreehelpCentrenumber1950forassistance*
Markonlyoneoval.

Ididnotknowthisnumber
I'mawareof1950servicebutdidn'trequirehelp
Icalled1950withsatisfactoryresults
Itried1950withunsatisfactoryresults
24.ADD.DETAILS:Assistanceduringvotingprocess*
Thisisamandatorybox.Elaboratedetails/reasonsfromquestion(s)aboveortypeNAifnothing
furthertoadd

Q&A:FEEDBACK/DIFFICULTYINTHEFOLLOWINGHUMAN
INTERFACEAREAS

INSTRUCTIONS:
1)Selectwhicheveroptionsapplyfromquestion'scheckboxes
2)Elaboratedetails/reasonsinADD.DETAILSboxthatfollowsortypeNAifnothingfurthertoadd

TIPSONDIFFICULTIESFACEDWITHHUMANINTERFACEINTERACTIONS

Eg:
>Barriersyouencounteredinsideyourpollingbooththatpreventedyoufromvotingprivatelyand
independentlyinadignifiedway.(forexample,attitudesofpollworkers,assistancerequiredetc.)
>AnydifficultyfacedinvotingbecauseofstatesIDrequirement.
>Ifyoureligibilitytovotewasquestioned,howdidthepollworkerhandlethesituation?
>Weretheelectionofficialscommunicatingwithorguidingonanyinformationrequest?
>Pleasedescribeprosandconsofoverallexperience

25.Difficultiesfacedinthefollowinghumaninterfaceareas*
Selectwhicheveroptionappliesfromthefollowing.Mandatoryquestionifnoissuesfacedselect
NOTAoptionatend
Checkallthatapply.

Officialuntrainedinwheelchairassistance
Officialuntrainedinsightedguidanceforvisuallyimpaired
Officialuntrainedinbasicsignlanguage
Assistancewasassumedandprovidedwithoutaskingfirst
Consentwasignored/overruled
Incompetencebias:Eligibilityquestionedduetodisability
CapabilityBias:Abilitytovoteindependentlyinprivacyquestioned
Denialofrequestedhelp/reasonableaccommodation
Undignifiedsigning/thumbprint/inkingprocess
Inappropriatetouch/invasionofbodyspace
Hurriedthroughprocessasimpatient/inconsiderate/overlyhelpful
NOTA:Ifacedzerohasslewithboothofficials!

Other:

26.ADD.DETAILS:Difficultiesfacedinhumaninterfaceareasmentionedabove*
Thisisamandatorybox.Elaboratedetails/reasonsfromquestion(s)aboveortypeNAifnothing
furthertoadd

ANYOTHERCOMMENTS:SUGGESTIONS/COMPLIMENTS/
CRITIQUE
27.AudiovisualEvidenceSubmission(photos/audio/videossupplementingtestimonyabove)*
EnterURLifsharedonlineinOPTIONS/OTHERbox
Markonlyoneoval.

Ihavenotgotanyfurtherinformationtosubmit
IwillsendsametoDRAemailathttp:/scr.im/drai

Other:

28.Observations,advice,whatever'sleftouttomakeyourinputscomplete*
Ifnothingmoretoadd,pleasetype'None'intheboxunderneath

TOFINISHFORM:SelectSUBMITbuttonbelowtosendyour
feedbacktoDRA

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