250 E Street, SW
Washington, D.C. 20525
202-606-5000 | 800-942-2677 | TTY 800-833-3722
TheCorporationforNationalandCommunityServiceiscommittedtoimplementingandadministeringaPrivacyPolicy
thatprotectsitsemployeesandotherindividuals’personallyidentifiableinformation(PII).ThisBreachNotificationForm
isavailabletoassistinproperlydocumentingasuspectedorconfirmedprivacybreach.Pleasecompletetheforminits
entiretyandreturntoprivacy@cns.govforprocessing.Completionofthisformdoesnotexcludeyoufromproperly
notifyingindividualsimpactedorfollowinglocalstatenotificationprocedures.
BreachReportedby:
Name: Supervisor:
Email: Email:
Phone: Phone:
Agency/Subagency/Component:
BreachOverview:
SummaryoftheBreach:
Donotincludeclassifiedinformation,sensitiveinformation,oranyunnecessaryPII.Summarizethefactsorcircumstancesofthetheft,loss,
orcompromiseofPIIascurrentlyknown,including:
a. Adescriptionofthepartiesinvolvedinthebreach;
b. Thephysicalorelectronicstoragelocationoftheinformationatrisk;
c.
Ifstepswereimmediatelytakentocontainthebreach;
d. Whetherthebreachisanisolatedoccurrenceorasystematicproblem;
e. Whoconductedtheinvestigationsofthebreach,ifapplicable;and
f. Anyotherpertinentinformation.
DateandTimeoftheBreach:
LocationoftheBreach:
NationalService.gov
TypeofBreach:
LostInformationorEquipment:
Yes
No
UnauthorizedDisclosure:
(e.g.,emailsenttoincorrectaddress,oralorwritten
disclosuretounauthorizedperson,disclosingdocuments
publiclywithsensitiveinformationnotredacted)
Yes
No
StolenInformationorEquipment:
Yes
No
UnauthorizedAccess:
(e.g.,anunauthorizedemployeeorcontractoraccesses
informationoraninformationsystem)
Yes
No
UnauthorizedEquipment:
(e.g.,usinganunauthorizedpersonaldevice,server,or
emailaccounttostorePII)
Yes
No
UnauthorizedUse:
(e.g.,employeewithagencyauthorizedaccesstodata base
orfileaccessesandusesinformationforpersonalpurposes
ratherthanforofficialpurposes)
Yes
No
StorageMedium:
LaptoporTablet: YesNo Smartphone: YesNo
Desktop: YesNo Paperfiles: YesNo
ITSystem:
(e.g.,Intranet/SharedDrive)
YesNo OralDisclosure: YesNo
ExternalStorageDevice:
(e.g.,CD,DVD,USBDrive)
YesNo
Email:
(Providetherelevantemailaddress,theagency,andadescriptionofthe
emailserver(e.g.,cloud,personal,private))
Other:
(Provideadetaileddescriptionofthemedium)
ReportedtoUSCERT,LawEnforcement,orCongress:
ReportedtoUSCERT: YesNo
Ifanyareyes,completethefollowing:
ReportedtoLawEnforcement: YesNo
ReportedtoCongress: YesNo
Nameofrecipient(s):
Titleofrecipient(s):
Emailofrecipient(s):
Phoneofrecipient(s):
AgencyandComponent:
DateandTimeoftheReport:
NumberofIndividualsandSafeguards:
Numberofindividualspotentiallyaffectedbythebreach:
Wastheinformationunstructured:
(e.g.,openfieldsonaformorsurvey)
YesNo
WastheinformationencryptedviaaNISTvalidatedmethod: YesNo
Doesaduplicatesetofthepotentiallycompromisedinformationexist: YesNo

NationalService.gov
AdditionalInformation:
Internalbreach(e.g.,withintheagency’snetwork),external,both,orunknown:
Whatcountermeasures,ifany,wereenabledwhenthebreachoccurred:
(ListallapplicablecountermeasuresandwhethereachonewasNISTcertified(e.g.,harddriveencryptiononlaptop,encryptionofelectronicfiles,
passwordonsmartphone)
Whatsteps,ifany,havealreadybeentakentomitigatepotentialharm:
(e.g.,callingorsendingseparateemail(s)torecipie nt(s)ofanunauthorizedemailtorequestdeletionoforiginalemail,contactingwebpub lishingto
removeunredacteddocumentsfrompublicwebsite)
Doyouhaveknowledgethatanyinformationinvolvedinthebreachwasintentionallystolenormisused:
(Ifyes,describethebasisforyourknowledgeandhowtheinformationmayhavebeenmisused(e.g. ,evidenceofidentitytheft,hacking,adverse
publicity)
DataElementsandInformationTypes:
IdentifyingNumbers
SocialSecuritynumberTruncatedorPartialSocialSecuritynumber
Driver’sLicenseNumberLicensePlateNumber
DEARegistrationNumber File/CaseIDNumber
PatientIDNumber HealthPlanBeneficiaryNumber
StudentIDNumberFederalStudentAidNumber
PassportnumberAlienRegistrationNumber
DODIDNumberDODBenefitsNumber
EmployeeIdentificationNumberProfessionalLicenseNumber
TaxpayerIdentificationNumber
BusinessTaxpayerIdentificationNumber
(sole
proprietor)
Credit/DebitCardNumberBusinessCreditCardNumber
(soleproprietor)
VehicleIdentificationNumberBusinessVehicleIdentificationNumber
(soleproprietor)
PersonalBankAccountNumberBusinessBankAccountNumber
(soleproprietor)
PersonalDeviceIdentifiersorSerialNumbers
Businessdeviceidentifiersorserialnumbers
(sole
proprietor)
PersonalMobileNumberBusinessMobileNumber
(soleproprietor)

NationalService.gov
BiographicalInformation
Name
(includingnicknames)
GenderRace
DateofBirth
(Day,Month,Ye ar)
Ethnicity Nationality
CountryofBirthCityorCountyofBirthMaritalStatus
CitizenshipImmigrationStatusReligion/ReligiousPreference
HomeAddressZipCodeHomePhoneorFaxNumber
SpouseInformationSexualOrientationChildrenInformation
Group/Organization
Membership
MilitaryServiceInformationMother’sMaidenName
BusinessMailingAddress
(sole
proprietor)
BusinessPhoneorFaxNumber
(soleproprietor)
GlobalPositioningSystem
(GPS)/LocationData
PersonalemailaddressBusinessemailaddress EmploymentInformation
PersonalFinancialInformation
(includingloaninformation)
BusinessFinancialInformation
(includingloaninformation)
Alias
(e.g.,username,screenname)
EducationInformationResumeorcurriculumvitaeProfessional/personalreferences
Biometrics/DistinguishingFeatures/Characteristics
FingerprintsPalmprintsVascularscans
Retina/IrisScansDentalProfile Scars,marks,tattoos
HairColorEyeColorHeight
VideorecordingPhotosVoice/AudioRecording
DNASampleorProfileSignaturesWeight
Medical/EmergencyInformation
PhysicalHealthInformationMentalHealthInformationDisabilityInformation
Workers’Compensation
Information
PatientIDNumberEmergencyContactInformation
DeviceInformation
Devicesettingsorpreferences
(e.g.,securitylevel,sharingoptions,
ringtones)
Celltowerrecords
(e.g.,logs,user
location,time)
Networkcommunicationsdata
SpecificInformation/FileTypes
TaxpayerInformation/Tax
ReturnInformation
LawEnforcementInformation
SecurityClearance/Background
CheckInformation
Civil/CriminalHistory
Information/PoliceRecord
AcademicandProfessional
BackgroundInformation
HealthInformation
CasefilesPersonnelFilesCreditHistoryInformation

AdditionalInformation