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 June 2008 INFORMATION SECURITY INCIDENT REPORT c) If a Privacy Disclosure Notice is required, attach a sample of the notification..
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