Incident Reporting
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Incident Summary
Type of Incident Detected
*
Choose an incident type
Denial of service
Malicious code
Unauthorized use
Unauthorized access
Espionage
Probe
Hoax
HIPAA breach
Other
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General Info
Anonymous submission?
Yes
No
Name
*
First
Last
Title
Phone
Email
*
Date / Time Detected
*
Date
Time
Location Incident Detected From
*
Additional Information
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Incident Location
Site
Site Point of Contact
Phone
Email
How was the incident detected?
Additional Information
Location(s) of affected systems:
Date and time incident handlers arrived at the site:
Date
Time
Describe affected information system(s)
Hardware manufacturer
Serial Number
Corporate Property Number
Is the affected system connected to a network
Yes
No
Describe the physical security of the location affected information systems ( locks, security, alarms, building access, etc.)
Other Incidents Related to this Incident:
Breach Incident Status
Choose a status
New
In progress
Forwarded for investigation
Resolved
Incident Summary
Incident Description
Date and Time Incident Discovered:
Date
Time
Date and Time Incident Reported:
Date
Time
Date and Time Incident Occurred:
Date
Time
Personnel Involved in Incident:
Type and Volume of Information Involved:
Accessibility/Vulnerability of ePHI / Protective Controls in Place: (e.g. Encryption, etc.):
Indicators of Compromise Related to the Incident:
Root Cause of Incident:
Awareness of Incident (who knows about it now):
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Isolate affected systems
Approval to remove from network?
Yes
No
if Yes, name of Approver
Date and Time Removed
Date
Time
If No, state the reason
Initial Risk Assessment
Number of Individuals Potentially Affected:
Potential Privacy Breach (Yes/No):
Yes
No
Risk to Individuals (Types and Extents):
Financial Risk to Organization:
Legal/Contractual Risk to Organization:
Regulatory Risk to Organization:
Public Relations Risk to Organization:
ePHI Accessed or Modified in an Unauthorized Manner (Yes / No):
Yes
No
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Backup of Affected Systems
Last System backup successful?
Yes
No
Name of persons who did backup
Date and time last backup started
Date
Time
Date and time last backup completed
Date
Time
Backup Storage Location
Steps Taken
Current Actions Taken:
Evidence Gathered / Chain of Custody:
People Contacted: (e.g., system owners, system administrators, Law enforcement, outside counsel, forensics investigators):
Data Breach Services Provider Contacted:
Agencies Notified:
Close or Move to Investigation Phase and Why:
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Incident Eradication
Name of persons performing forensics
Was the root cause identified?
Yes
No
Desribe root cause findings
How was eradication validated
Notification
Covered Entity(s) (CE) Affected:
Date Covered Entity(s) (CE) Notified:
Date
Time
Method(s) used to Notify Covered Entity(s) (CE):
Notification Record (Ticket # Documenting Notification):
System Generated List of Individuals Affected Attached (Required):
Click or drag a file to this area to upload.
Supporting Details:
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Upload any relevant information pertinent to the incident (i.e. emails, screenshots, etc)
Click or drag files to this area to upload.
You can upload up to 5 files.
*File must be under 512MB. Supported file types: Images: jpg, jpeg, png, gif, ico, pdf, doc, docx, ppt, pptx, pps, ppsx, odt, xls, xlsx, psd, mp3, m4a, ogg, wav, mp4, m4v, mov, wmv, avi, mpg, ogv, 3gp, 3g2
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