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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 applicable, 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 disclosure 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 others 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