| (a) Location of incident and organization filing
report;__________________________________________________ |
| __________________________________________________________________________________________ |
| (b) Reported by (Name, Title and
Organization);_____________________________________________________ |
| __________________________________________________________________________________________ |
| (c) Date and time of report
filing;_________________________________________________________________ |
| __________________________________________________________________________________________ |
| (d) Date and time of incident;
___________________________________________________________________ |
| __________________________________________________________________________________________ |
| (e) Details of incident (include names of personnel
involved and description of the who, what, when, where, how, and
why);_____________________________________________________________________________________ |
| _________________________________________________________________________________________ |
| (f) The name and title of the person to whom the
incident initially was reported to;____________________________ |
| _________________________________________________________________________________________ |
| (g) Identification of whether the Inspector General or
appropriate law enforcement organization has been notified;____ |
| _________________________________________________________________________________________ |
| (h) Incident impact on day-to-day
operations;_______________________________________________________ |
| _________________________________________________________________________________________ |
| (i) Action taken to contain the incident and resources
required to correct the incident (in cases of system outage note what
vendors have been
contacted);____________________________________________________________ |
| _______________________________________________________________________________________ |
| (j) Short-range corrective action, such as
discontinuing the use of an infected computer diskette, immediately
removing a terminated employee's access
privileges;___________________________________________________________ |
| _________________________________________________________________________________________ |
| (k) Long-range corrective actions, as
necessary;_____________________________________________________ |
| _________________________________________________________________________________________ |
| (l) Estimated monetary
damage;_________________________________________________________________ |
| _________________________________________________________________________________________ |
| (m) Additional information, as
appropriate;_________________________________________________________ |
| _________________________________________________________________________________________ |