IT Incident Report Form

• Incident Numer

• Name of person involved

• Date & Time of Incident

  Date

• Reported By

• Location
  Address

• 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
  Address

Incident Description

• Provide a brief description

• Date & time incident was discovered

  Date

• Have the incident been resolved

  Yes

  No

  N/A

• 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?

  Yes

  No

• Please describe

Impact/potential impact

• Select all that apply to this incident

  Select Loss / Compromise of Data Damage to Systems System Downtime Financial Loss Other Organization's Systems Affected Integrity Damage Violation of legislation Other

  • Loss / Compromise of Data
  • Damage to Systems
  • System Downtime
  • Financial Loss
  • Other Organization's Systems Affected
  • Integrity Damage
  • Violation of legislation
  • Other

• Provide a brief description

Completion

• Observations and comments

• Name & signature of person reporting

  Sign