INFORMATION SECURITY INCIDENT REPORT TEMPLATE

REPORTED BY:	DATE OF REPORT:
TITLE / ROLE:	INCIDENT NO.:

INCIDENT ASSESSMENT:	NEGLIGIBLE:	MINOR:	SIGNIFICANT:	CRITICAL:

INFORMATION SECURITY INCIDENT INFORMATION
DATE OF INCIDENT:	TIME OF INCIDENT:
INCIDENT MANAGER:	TITLE / ROLE:
PHONE:	EMAIL:
LOCATION:
SPECIFIC AREA OF LOCATION (if applicable):
INCIDENT TYPE:
NO. OF HOSTS AFFECTED:	SOURCE IP ADDRESS:
IP ADDRESS:	COMPUTER / HOST:
OPERATING SYSTEM:	OTHER APPLICATIONS:
INCIDENT DESCRIPTION:
IMPACT ASSESSMENT:
RESULTING DAMAGE:
IMMEDIATE ACTION TAKEN:
PLANNED ACTION AND RESULTING PREVENTATIVE MEASURES:
ADDITIONAL INFORMATION:

INFORMATION SECURITY INCIDENT INFORMATION SHARING
DEPARTMENT REQUIRING NOTIFICATION	POINT OF CONTACT NAME	DATE OF NOTIFICATION
REPORTING STAFF NAME:	REPORTING STAFF SIGNATURE:	DATE:
SUPERVISOR NAME:	SUPERVISOR SIGNATURE:	DATE:

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