Free Incident Report Template 49Free Incident Report Template 49Free Incident Report Template 49
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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
Organization Name:
Organization Address:
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)
☐ Reconnaissance

☐ Malware

☐ Data Exfiltration

☐ Other (please
describe)

3. What equipment and/or systems have been impacted?
Type:
Manufacturer:
Model Number:
Serial Number:
4. What operating system(s) was (were) installed on the equipment at the time of the intrusion?
OS:

OS:

OS:

Version:

Version:

Version:

Time Zone:

Time Zone:

Time Zone:

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