DATA INCIDENT REPORTING TEMPLATE
Incident Reporting Template
This is a sample template outlining typical information which may be requested by law enforcement and
regulatory agencies. It is intended as a starting point for both internal and external incident reporting. For
updates to this form and related information visit https://otalliance.org/Breach.
1. Organization Information
Name of Person Reporting:
Name of Network Administrator:
Name of CISO:
Name of CIO/Executive Level Decision Maker:
Date of Report:
2. What type of network compromise has occurred? (please select all that apply)
☐ Data Exfiltration
☐ Other (please
3. What equipment and/or systems have been impacted?
4. What operating system(s) was (were) installed on the equipment at the time of the intrusion?