Cybersecurity Human Error Incident Report Form
Report a cybersecurity incident caused by human error so the security team can assess impact and take action.
Incident Reporter Information
Full Name
*
First Name
Last Name
Job Title / Role
*
Department / Team
*
Work Email
*
example@example.com
Work Phone / Extension
Please enter a valid phone number.
Format: (000) 000-0000.
Preferred Contact Method
Email
Phone
Either
Incident Details
Incident Date
*
 -
Month
 -
Day
Year
Date
Incident Time
*
Hour Minutes
AM
PM
AM/PM Option
Date/Time Discovered
*
 -
Month
 -
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
Incident Location or Environment
*
Please Select
Office
Remote
Cloud System
Device
Application
Email
Network
Other
Incident Category
*
Please Select
Phishing Click
Mis-sent Email
Misconfiguration
Weak Password Handling
Lost Device
Accidental Data Sharing
Improper Access Grant
Other
Short Incident Summary
*
Affected System, Device, or Application
Human Error and Impact Assessment
Suspected human error type
*
Please Select
Phishing response mistake
Misaddressed email/message
Improper file sharing
Unauthorized disclosure
Weak verification procedure
Configuration mistake
Policy bypass
Accidental deletion
Other
Who was involved or affected?
*
Internal users only
External recipients/users only
Both internal and external users
Unclear
Systems or applications affected
*
Data or information impacted
*
Estimated impact level
*
Low
Medium
High
Critical
Could confidential or sensitive data have been exposed?
*
Yes
No
Uncertain
Is the issue ongoing or contained?
*
Ongoing
Contained
Uncertain
Discovery and Immediate Response
How was the incident discovered?
*
Self-reported
Colleague reported
Monitoring alert
Customer report
Security team found it
Other
Immediate actions already taken
*
Recalled email
Disabled account
Changed password
Revoked access
Isolated device
Notified IT/security
Other
Were credentials changed?
*
Yes
No
Not applicable
Was access restored or blocked?
*
Access restored
Access blocked
Partially restored
Not sure
Upload screenshots, logs, or other evidence
Upload a File
Drag and drop files here
Choose a file
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of
Notification and Follow-Up
Who has been notified?
*
IT
Security
Manager
Legal
Privacy
HR
None yet
Is further assistance required?
*
Yes
No
Not sure
Priority for follow-up
*
Please Select
Low
Medium
High
Urgent
Recommended corrective action or training needed
Additional comments or details
Submit Report
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