Cybersecurity Infraction Reporting Form
Use this form to report suspected cybersecurity incidents, security policy violations, or unusual activity so the issue can be reviewed promptly.
Reporter Information
Reporter Name
First Name
Middle Name
Last Name
Organization / Department
*
Job Title / Role
*
Work Email
example@example.com
Work Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Incident Details
Incident Date and Time
*
-
Month
-
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
Date Discovered
*
-
Month
-
Day
Year
Date
Location / System / Application Involved
*
Infraction Type
*
Phishing
Malware
Unauthorized Access
Data Exposure
Suspicious Email
Policy Violation
Lost Device
Account Compromise
Other
Description of What Happened
*
Is the Issue Ongoing?
*
Yes
No
Unknown
Immediate Actions Already Taken
Isolated affected device
Changed affected account credentials
Notified IT/Security team
Deleted or quarantined suspicious email
Preserved evidence
Contacted manager
Other
Additional Incident Details
Impact and Evidence
Affected assets, systems, accounts, or data
*
Workstations
Servers
Cloud services
Email accounts
User accounts
Databases
Network devices
Source code repositories
Customer data
Internal documents
Other
Severity / impact level
*
Low
Moderate
High
Critical
Who was impacted
No known impact
Internal employees
Customers
Contractors
Vendors
Business partners
Other
Suspected indicators of compromise or other evidence
People or teams already notified
Supporting evidence files
Upload a File
Drag and drop files here
Choose a file
Cancel
of
Preferred follow-up method
*
Email
Phone
No follow-up (anonymous)
Submit Report
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