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PII INCIDENT FORM

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Fill the form below and submit to report a Personally Identifiable Information (PII) incident.

Main Point of Contact For More Information
Unit Office Name and Mailing Address
Breach Information
Date of Actual Breach
Date of Breach Discovery
US-Cert Date Reported
Was the breach the result of a willful and intentional act (i.e. a Privacy Act violation)?
Individuals Notified?
Notification Date
Credit Monitoring Offered?
Type of Personally Identifiable Information involved in the incident
If Financial Information is selected more information is needed
Select all of the following that apply to the incident
If Paper Records or Record Disposal was selected provide more detail
Paper records faxed or mailed accidentally
Paper records disposed of improperly
Unauthorized disclosure of paper records
Documents posted to Internet
Documents posted to Intranet
If Equipment was selected provide more detail
Equipment involved # of items
If Email or Info Sharing was selected provide more detail
Email was encrypted
Email was digitally signed
Email was sent outside the DoD
Email recipients non-Federal agency
Information was
posted to the Internet
posted on an Intranet
Saved on a share drive
disclosed verbally
Investigation
Impact Determination
Impact determination is
Is there an associated System of Record
Additional Notes