Doc Ref No.

19-RSMS02-02
Philippine Statistics Authority
Quality Management System Effective Date 21 October 2019
Infrastructure and Systems Management Division Revision No. 0
INCIDENT REPORT FORM Page 1 of 2

Reference No:
Date Prepared: 13 JULY 2021

1. CONTACT INFORMATION FOR THIS INCIDENT:

NAME NORI ZYVE A. MANAGBANAG

DESIGNATION/POSITION Registration Center Supervisor
CONTACT NUMBER 09610959429
E-MAIL ADDRESS norizyve@gmail.com
DIVISION/SERVICE/OFFICE PhilSys Registration Center – Baybay City Gymnasium

2. INCIDENT DESCRIPTION:

ERROR ID: SALVADOR U. CARBONILLA JR.

SEX INDICATED IN THE PHILID IS FEMALE INSTEAD OF MALE.
REGISTRANT WAS CERTAIN THAT HE AND THE RKO CHECKED IT AT LEAST 2 TIMES BEFORE PRINTING.

3. IMPACT/ POTENTIAL IMPACT

☐ Loss/ Compromise of Data

☐ Damage to the ICT hardware components
☐ Damage to the ICT software components
☐ System Downtime
☐ Financial Loss
☐ Damage to the Integrity or Delivery of Services or Information
☐ Violation of Legislation/Regulation
☒ Unknown currently
☐ Damage or loss of other ICT resources, specify:

4. SENSITIVITY OF DATA/ INFORMATION INVOLVED

☐ Public
☐ Internal Use Only
☐ Restricted / Confidential (Privacy Violation)
☒ Unknown/ Other, please describe:

5. WHO ELSE HAS BEEN NOTIFIED?

1. PSA FEEDBACK & GRIEVANCE DIVISION

6. WHAT STEPS HAVE BEEN TAKEN SO FAR?

☐ No action taken
☐ System disconnected from network
☐ Updated virus definitions and scanned system
☐ Restored backup
☐ Log files examined (saved secured)
☒ Other, please describe:

SUBMITTED REPORT OF ERROR TO THE PSA FEEDBACK & GRIEVANCE DIVISION.

 Doc Ref No. 19-RSMS02-02
7.
Philippine Statistics Authority
Quality Management System Effective Date 21 October 2019
Infrastructure and Systems Management Division Revision No. 0
INCIDENT REPORT FORM Page 2 of 2

INCIDENT DETAILS

Date and time the incident was discovered: MAY 26, 2021

Has the incident been resolved? NO

Physical location of affected system(s) N/A

Number of sites affected by the incident N/A

Approximate number of systems affected by the N/A

incident.

Approximate number of users affected by the incident. N/A

Additional information that you feel is important but N/A

has not been provided elsewhere on this form.

ADD PHOTO(S) AS EVIDENCE:

Reported & Prepared by: Noted by:

NORI ZYVE A. MANAGBANAG, RCS FORTUNE DILAO, ISA I

Signature over Printed Name and Position Signature over Printed Name and Position