Scribd
Upload
26 views

Security Incident Report Form

Uploaded by

karmaagricfeeds
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
26 views

Security Incident Report Form

Uploaded by

karmaagricfeeds
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
You are on page 1/ 3

IT Security Incident Reporting Form

Instructions: This form is to be completed as soon as possible following the detection or


reporting of an Information Technology (IT) security incident. All items completed should
be based on information that is currently available. This form may be updated and modified
if necessary.

1. Contact Information for this Incident


Name:
Title:
Program Office
Work Phone:
Mobile Phone:
Email address:
Fax Number:
2. Incident Description.

Provide a brief description:

3. Impact / Potential Impact Check all of the following that apply to this incident.
 Loss / Compromise of Data
 Damage to Systems
 System Downtime
 Financial Loss
 Other Organizations’ Systems Affected
 Damage to the Integrity or Delivery of Critical Goods, Services or Information
 Violation of legislation / regulation
 Unknown at this time
Provide a brief description:

Page 1 of 3
4. Sensitivity of Data/Information Involved Check all of the following that apply
to this incident.
Sensitivity of Data
Category Example
Public This information has been specifically approved for public
release by Public Relations department or Marketing
department managers. Unauthorized disclosure of this
information will not cause problems for Department of Public
Welfare, its customers, or its business partners. Examples are
marketing brochures and material posted to Department of
Public Welfare web pages. Disclosure of agency information to
the public requires the existence of this label, the specific
permission of the information Owner, or long-standing practice
of publicly distributing this information.
Internal Use Only This information is intended for use within Department of
Public Welfare or between agencies, and in some cases within
affiliated organizations, such as business partners.
Unauthorized disclosure of this information to outsiders may
be against laws and regulations, or may cause problems for
the Department of Public Welfare, its customers, or its
business partners. This type of information is already widely
distributed within the Department of Public Welfare, or it could
be so distributed within the organization without advance
permission from the information owner. Examples are an
agency telephone book and most internal electronic mail
messages.
Restricted/ This information is private or otherwise sensitive in nature and
Confidential must be restricted to those with a legitimate business need for
(Privacy Violation) access. Unauthorized disclosure of this information to people
without a business need for access may be against laws and
regulations, or may cause significant problems for the
Department of Public Welfare, its customers, or its business
partners. Decisions about the provision of access to this
information must be cleared through the information owner.
Examples are customer transaction account information and
worker performance evaluation records. Other examples
include citizen data and legal information protected by
attorney-client privilege.
Unknown/Other Describe in the space provided

 Public  Restricted / Confidential (Privacy


 Internal Use Only violation)
 Unknown / Other – please describe:
Provide a brief description of data that was compromised:

Page 2 of 3
5. Who Else Has Been Notified?
Provide Person and Title:

6. What Steps Have Been Taken So Far? Check all of the following that apply to
this incident.
 No action taken  Restored backup from tape
 System Disconnected from network  Log files examined (saved &
 Updated virus definitions & scanned secured)
system  Other – please describe:
Provide a brief description:

7. Incident Details
Date and Time the Incident
was discovered:
Has the incident been
resolved?
Physical location of affected
system(s):
Number of sites affected by the
incident:
Approximate number of
systems affected by the
incident:
Approximate number of users
affected by the incident:
Are non-Commonwealth
systems, such a business
partners, affected by the
incident?
(Y or N – if Yes, please
describe)
Please provide any additional
information that you feel is
important but has not been
provided elsewhere on this
form.
Please submit this completed form to:
[email protected]
or Fax to 123-456-7890

Page 3 of 3

You might also like