Fill and Sign the Cybersecurity it Incident Report Template PDF Word Form

CYBERSECURITY (IT) INCIDENT REPORT FORM Use this form to report any cybersecurity issues, breaches, hacks, malware, or any other incidents involving a 3rd party. Date of Report: _________________, 20____ CONTACT PERSON Full Name: _________________ Address: __________________________________ Job Title: __________________________ Phone: (____) ____-_____ E-Mail: _________________ THE INCIDENT Date of Incident: _________________, 20____ Time: ____:_____ ☐ AM ☐ PM Type of Incident: ☐ Malware ☐ Data Breach ☐ Other: __________________________ How was the incident detected / discovered? __________________________________ NOTIFICATION Were other personnel notified? ☐ Yes ☐ No If yes, enter: _________________________________________________________ CONTAINMENT Were any containment measures made? ☐ Yes ☐ No If yes, describe: _______________________________________________________ IMPACTED SERVICES Was anything permanently impacted by the incident? ☐ Yes ☐ No If yes, describe: _______________________________________________________ Page 1 of 2 ATTACK VECTOR Do you know how the attack was made? ☐ Yes ☐ No If yes, describe: _______________________________________________________ INFORMATION IMPACT Was there any data, records, or information breached? ☐ Yes ☐ No If yes, describe: _______________________________________________________ OTHER Is there any other information you would like to include in this report? ☐ Yes ☐ No If yes, describe: _______________________________________________________ OFFICE USE ONLY Report received by: _________________ Date: _________________, 20____ Follow-up action taken: ___________________________________________________ Page 2 of 2