Cyber Security Incident Report: Electronic Physical

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Cyber Security Incident Report

Revised 05/31/2016

Office of Technology Services


Security Incident Reporting Form

Reported By:       Phone No.      


Email: Date Reported:      
Agency:       Device Type:      
Name of Individual Affected:       Location/Address of Problem:      
User Description of Problem:      

Incident Type

Electronic Physical
User Compromise Unauthorized Access
Compromised/Stolen/Altered Data Access Control Avoidance
Theft and use of Others ID’s Equipment Stolen or Damaged
Personal Identifying Information (PII) Other
Other If Other Please Explain:
If Other Please Explain:

Misuse of Resources
Unauthorized Use of Remote Control Malicious Code Activity
Unauthorized Use of Software Virus Scan Engine Version _____________
Inappropriate Use of Email DAT Version _____________
Inappropriate Use of State Resources Date of Last Virus Scan ___________
Inappropriate Use of Internet EPO Agent Installed
Unauthorized Solicitation Spam
Illegal Log-in Attempt Other
Hoaxes
If Other Please Explain:
Storage and/or Distribution of illegal Software
Other
If Other Please Explain:

The below items are to be filled out by Administrative & Program Support Branch only

Investigated by:       Evidence Collected (choose) YES


NO
Number of Intruders:       Number of Hosts:      
Incident Source:       Analysis of Findings:
Recommended Action:      
Additional Comments:      

Please send form to EDU.SECURITYREQUEST@KY.GOV

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