Incident Detector’s Information

Name:

Today’s Date:

Department:

Location:

Phone/Contact Info:

System/Application

INCIDENT SUMMARY

 

 

 

 

 

 

 

 

Type of Incident Detected:

Denial of Service

Unauthorized Access

☐ Malicious Code

☐ Unplanned Downtime

☐ Unauthorized Use/Disclosure

☐ Other .

Date/Time Detected:

 

Description of Incident

 

 

 

 

 

Names and Contact Information of Others Involved

 

 

 

 

 

INCIDENT NOTIFICATION - OTHERS

☐ IS VP

☐ Administration

 

System or Application Owner

Human Resources

 

Systems and Application Vendor

Other .

ACTIONS AND RECOMMENDATIONS

Investigator:

Date:

Summary of Findings

 

 

 

 

 

 

 

Recommendation (if any) for Additional Corrective Action

 

 

 

 

 

 

Copy of Completed Form Mailed to Appropriate VPs as Incident is Closed:

VPs Name:

 

 

 

Date Sent: