Inspection

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.

Contact Information for this Incident

Name

Job Title

Store/Department

Contact number

Email address

Work Address
Incident Description

Provide a brief description

Date & time incident was discovered

Have 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 systems affected by the incident

Are non-Commonwealth systems, such as business partners, affected by the incident?

Please describe

Impact/potential impact
Select all that apply to this incident

Provide a brief description

Completion

Observations and comments

Name & signature of person reporting