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PII INCIDENT FORM

Fill the form below and submit to report a Personally Identifiable Information (PII) incident.

Initial Report
Report Date
Updated Report
After Action Report
General Information
Date of Actual Breach
Date of Breach Discovery
US-Cert Date Reported
Main Point of Contact For More Information
Mailing Address
Breach Information
Number of Indivduals Affected
Were affected Individuals Notified?

If Yes, Were they notified with in 10 working days

If Yes, Notification Date
If applicatble, Credit Monitoring Offered?


Type of Personally Identifiable Information involved in the incident










If Financial Information is selected more information is needed



Select all of the following that apply to the breach




If Paper Records or Record Disposal was selected provide more detail
Paper document faxed



Paper documents/records mailed



Paper document/records disposed of improperly



Unauthorized diclosure of paper documents/records



If Equipment was selected provide more detail
Equipment involved # of items
If Email or Info Sharing was selected provide more detail
Email was encrypted


Email was sent to commercial account(i.e., .com or .net)


Email was sent to other Federal agency


Email recipients had a need to know


Information Dissemination
Information was posted to the Internet


Information was posted on an Intranet(e.g., SharePoint or Portal


Information was accessible to other without need-to-know on a share drive


Information was disclosed verbally


Impact Determination
Impact determination (for Component Privacy Official or designee only)


Additional Notes