Title Page

  • Incident Numer

  • Name of person involved

  • Date & Time of Incident

  • Reported By

  • Location
  • 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


  • Observations and comments

  • Name & signature of person reporting

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.