Information Security Incident Report

INFORMATION SECURITY INCIDENT REPORT
Department:
Incident
Number: (For Information Security Office only)
A. Notification
1. Date of notification to the Chief Information Security Officer or Departmental
Information Security Representative (ISAC member):
B. Incident Information
1. Details of Incident:
a) Date incident occurred: Unknown
b) Date incident detected: Unknown
c) Incident location:
d) General description:
e) Media/Device type, if applicable:

Was the portable storage device encrypted? Yes No
If NO, explain:
f) Describe the costs associated with resolving this incident:
g) Total estimated cost of incident:
2. Incidents involving personally identifiable information

a) Was personally identifiable information involved? Yes No (If No, go to Part C)
Type of personally identifiable information (Check all that apply)
Name Health or Medical Information
Social Security Number Financial Account Number
Driver's License/State ID Number
Other (Specify)
b) Is a Privacy Disclosure notice required? Yes No
Information Security Incident Report

c) If a Privacy Disclosure Notice is required, attach a sample of the notification.
d) Number of individuals affected:

e) Date notification(s) made:
C. Corrective Actions Planned/Taken to Prevent Future Occurrences:
1. Estimated cost of corrective actions:

2. Date corrective actions will be fully implemented:
D. Names:
Departmental ISR (ISAC Member*) (Date)

* See http://security.co.contra-
costa.ca.us/ISAC/email.htm
for ISAC members by department
INSTRUCTIONS
Department Head (or Designee) (Date)
Route completed Incident Report to the following address or e-mail to
Following these instructions to complete this form and send the a copy to the Information
Security Office within ten (10) business days from the incident. Do not send these instructions
with the report.
The following instructions will assist in completing the form. All questions must be completed as
applicable, even in a case where the response is a future action.
Department – Provide your Department full name.
Incident Notification Number – Completed by the Information Security Office.
A. Notification
Date of notification to the Chief Information Security Officer or Departmental Information
Security Representative (ISAC member)
B. Incident Information
1. Details of incident – Provide the date the incident occurred and the date the incident
was detected, if known. In the general description field, provide an overview of the
incident, with enough details so that the incident can be easily understood. Do not
include any personally identifiable information (such as social security numbers, home
addresses, etc.). Your report should include the following information as applicable:
a) Date incident occurred.

b) Date incident discovered.
c) Incident location – Provide the location where the incident occurred. For
example, if a laptop was stolen from an employee's home, suggested content
might be, "Employee's Home, Concord, CA" or, if the incident occurred at the
Department's headquarters office, suggested content might be, "Department's
Headquarters, 123 Any Street, Martinez, CA"
d) General description – include the following in the description:

• When the incident occurred and how it was discovered.
• The effect of the incident on the business and infrastructure of your
Department.
• The number of people (inside your Department and outside your
Department) affected by this incident.
• The effects if any of this incident to people, businesses or services outside
of your Department.
• The details of any law enforcement investigation of this incident such as
which Department investigated it, when, and the report number.
• Any personal, confidential, or sensitive information involved.
INSTRUCTIONS
e) Media/Device type, if applicable – Provide the type of media or device

involved in the incident such as paper (fax, mail, etc.) or electronic (CD, floppy
drive, laptop, PDA, email, etc.).
• Was the portable storage device encrypted? – Check appropriate box.
If NO, describe why the storage device was not encrypted.
f) Describe the costs associated with resolving this incident – Provide a cost
estimate of resolving the incident. Cost should include everything necessary to
resolve the incident including hardware, software, staff time, contracting services,
and any other pertinent costs that were triggered due to the incident. It should
also include costs associated with a disclosure notification (such as preparation,
postage, call center activation, etc.).
g) Total estimated cost of incident – Provide the total cost associated with
handling the incident as it relates to information technology including the cost to
replace any stolen equipment and/or software. For example, if a County vehicle is
stolen with a County-issued laptop in it; do not include the cost of the County
vehicle.
2. Incidents involving personally identifiable information
a) Was personally identifiable information involved? – Check appropriate boxes.

b) Is a privacy disclosure notice required? - Check appropriate box.
c) Sample – If yes, attach a sample copy of the notification sent to the affected
individuals. DO NOT provide a sample that includes personally identifiable
information.
d) Number of individuals affected – Identify the number of individual's whose
personally identifiable information was breached.
e) Date notification(s) made – Provide the date that the Notifications were made to
the affected individuals.
C. Corrective Actions Planned/Taken to Prevent Future Occurrences – Provide a detailed

description of the corrective actions taken by the Department to prevent future occurrences
of a similar incident occurring again.
1. Estimated cost of corrective actions – Provide cost estimations to implement the

corrective actions. For example, hardware and/or software may need to be upgraded,
installed or purchased; new policies may need to be developed, additional training
may need to be given. Include all related costs such as staff time, contracting
services, and hardware or software purchases.
2. Date corrective actions will be fully implemented – Provide a date when the
corrective actions were, or will be, fully implemented.
D. Names – The Department's Information Security Representative and Department Head will
report all incidents.
Route the completed Incident Report, without these instructions, as indicated on the form.

Information Security Incident Report

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INFORMATION SECURITY INCIDENT REPORT

e) Media/Device type, if applicable:

g) Total estimated cost of incident:

2. Incidents involving personally identifiable information

b) Is a Privacy Disclosure notice required? Yes No

Information Security Incident Report

d) Number of individuals affected:

C. Corrective Actions Planned/Taken to Prevent Future Occurrences:

1. Estimated cost of corrective actions:

Departmental ISR (ISAC Member*) (Date)

Department Head (or Designee) (Date)

Route completed Incident Report to the following address or e-mail to

Department – Provide your Department full name.

Incident Notification Number – Completed by the Information Security Office.

a) Date incident occurred.

d) General description – include the following in the description:

e) Media/Device type, if applicable – Provide the type of media or device

2. Incidents involving personally identifiable information

a) Was personally identifiable information involved? – Check appropriate boxes.

C. Corrective Actions Planned/Taken to Prevent Future Occurrences – Provide a detailed

1. Estimated cost of corrective actions – Provide cost estimations to implement the

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