PRIVACY IMPACT ASSESSMENT 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

SIGNATURES
REPORTING STAFF NAME	REPORTING STAFF SIGNATURE	DATE
SUPERVISOR NAME	SUPERVISOR SIGNATURE	DATE

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