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Data Security Incident Report Form
1
Your name
*
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2
Date and time of incident
*
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3
Duration of incident
*
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4
Location of incident
*
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5
What form was the affected data?
*
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Electronic
Physical
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6
Was the status of the affected data?
*
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At rest
In transit
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7
What data types were affected?
*
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8
How many records were affected?
*
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9
How was the incident discovered?
*
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10
Who discovered the incident?
*
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11
Detail, if known, any method of intrusion, entry or exit points, paths taken or systems compromised
*
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12
Nature of incident
*
This field is required.
Data was deleted
Data was compromised
Data was modified
Data was viewed by unauthorized person
Other
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13
What security measures (e.g. encryption) were in place?
*
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14
Who was affected?
*
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Employees
Members
Other
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15
What are the jurisdictions of residence for the affected individual(s)?
*
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City
County
State
Federal
Other
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