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| (Equipment Name and Serial Number) | | (Date of Election) |
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| (Equipment Name and Serial Number) | | |
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| (Signature of Operator |
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| (Jurisdiction) | | (Signature of Election Authority) |
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| ( I ) |
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| Pretabulation Test | | | |
| Begun | | Ended | | | | |
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| | | RUN MORE | |
| | NUMBER | THAN ONCE | |
| PRECINCT | TIME RUN | OF BALLOTS | (YES/NO) | IF YES, EXPLAIN |
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| 1. | | | | | |
| 2. | | | | | |
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| 5. | | | | | |
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| 9. | | | | | |
| 10. | | | | | |
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| 18. | | | | | |
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| 20. | | | | | |
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| Post-tabulation text: | Begun | | Ended | |
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| (II) |
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| WAS PROGRAM ACCESSED (CHANGED) BETWEEN PUBLIC TEST AND POST TEST? IF YES, WAS THE PROGRAM ACCESSED IN RESPONSE TO A CONSOLE MESSAGE, WHAT WAS THE CONSOLE MESSAGE AND WHAT WAS THE CHANGE, EXPLAN: |
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| Pretabulation Test Rerun Time: | Begun | | Ended | | |
| (III) | |
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| USE THIS SECTION TO REPORT REQUIREMENT REPAIRS OR REPLACEMENTS | |
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| TIME OF | | TIME BACK | | MACHINE |
| SERIAL NUMBER | | MALFUNCTION | | IN SERVICE | | REPLACED |
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| DESCRIPTION OF MALFUNCTION: | |
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| PRETABULATION TEST RERUN | | TIME: | BEGUN | | ENDED | | |
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(Source: Amended at 18 Ill. Reg. 14714, effective September 9, 1994)