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.,employeewithagency‐authorizedaccesstodata base
orfileaccessesandusesinformationforpersonalpurposes
ratherthanforofficialpurposes)
Yes
No
StorageMedium:
LaptoporTablet: YesNo Smartphone: YesNo
Desktop: YesNo Paperfiles: YesNo
ITSystem:
(e.g.,Intranet/SharedDrive)
YesNo OralDisclosure: YesNo
ExternalStorageDevice:
(e.g.,CD,DVD,USBDrive)
YesNo
Email:
(Providetherelevantemailaddress,theagency,andadescriptionofthe
e‐mailserver(e.g.,cloud,personal,private))
Other:
(Provideadetaileddescriptionofthemedium)
ReportedtoUS‐CERT,LawEnforcement,orCongress:
ReportedtoUS‐CERT: YesNo
Ifanyareyes,completethefollowing:
ReportedtoLawEnforcement: YesNo
ReportedtoCongress: YesNo
Nameofrecipient(s):
Titleofrecipient(s):
Emailofrecipient(s):
Phoneofrecipient(s):
AgencyandComponent:
DateandTimeoftheReport:
NumberofIndividualsandSafeguards:
Numberofindividualspotentiallyaffectedbythebreach:
Wastheinformationunstructured:
(e.g.,openfieldsonaformorsurvey)
YesNo
WastheinformationencryptedviaaNIST‐validatedmethod: YesNo
Doesaduplicatesetofthepotentiallycompromisedinformationexist: YesNo
