INCIDENT REPORTING FORM
Important: Initial notification must be exclusively made to the IHS Incident Response Team (IRT) no
later than 30 minutes from discovery. All incidents must also have a resolution completed.
Contact the IHS IRT: Email: IRT@ihs.gov; Business Hours: 1-888-830-7280 (OIT Help Desk).
After Hours: 702-562-8201 (NOSC).
Check One: Incident Notification Update Resolution
IR Primary Handler:
Does the incident involve Personally Identifiable Information (PII)? Yes No (if yes, complete PII box)
KEY INFORMATION
Date/Time of Incident Discovery: Date/Time Incident Occurred:
Facility name:
Discoverer of incident:
Contact person and contact information:
Alternate contact and contact information:
<If equipment was lost/stolen, list the government barcode number(s) for the stolen equipment>
<Describe the roles of the people involved, be it contractors, government employees, etc.>
<Number of individuals impacted/estimated to be impacted>
<List people to keep notified of incident and people who should NOT be notified>
INCIDENT SUMMARY
<High-level summary of incident, elaborating on key information above.>
Form F07-02b, related to SOP07-02 1 of 2 Version 1.5 - 1/2015
