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HOME
ABOUT DISA
LEGAL AND REGULATORY
PRIVACY OFFICE
PII INCIDENT FORM
PII INCIDENT FORM
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Add This
Fill the form below and submit to report a Personally Identifiable Information (PII) incident.
Main Point of Contact For More Information
POC First Name
POC Last Name
POC Rank/Title
POC Duty Email
POC Duty Phone
Unit Office Name and Mailing Address
Address 1
Address 2
City
State
Zip
Breach Information
Date of Actual Breach
Month
Day
Year
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2011
2012
2013
Date of Breach Discovery
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Day
Year
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2012
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US-Cert Date Reported
Month
Day
Year
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2001
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2007
2008
2009
2010
2011
2012
2013
US-CERT Number / Incident Number
Incident Involved
Click to Select
E-mail
Info-Sharing
Paper Records
Equipment
Incident Category
Click to Select
Compromise
Lost
Stolen
Computer Hacking
Equipment Malfunction
Failure to Follow Policy
Human Error
Social Engineering
Unknown
Other
Component
Description of breach
Describe actions taken in response to the breach
Was the breach the result of a willful and intentional act (i.e. a Privacy Act violation)?
Yes
No
Total Number of Individuals Affected
# Government Civilians
# Government Contractors
# Military Reserve
# Military Family Members
# Military Retired
# National Guard
# General Officers
# Senior Executive Officers
# Members of Congress
# Members of the Senate
# State Local Officials
# Family Members thereof
# Other (Specify below)
Individuals Notified?
Yes
No
Notification Date
Month
Day
Year
01
02
03
04
05
06
07
08
09
10
11
12
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
Credit Monitoring Offered?
Yes
No
If there was no notification explain why
Type of Personally Identifiable Information involved in the incident
Social Security Numbers
Date of Birth
Names
Protected Health Information (PHI)
Personal Email Address
Personal Home Address
DoD ID Number
DoD Benefits Number
Passwords
* Financial Information (provide additional details below)
Other (Specify below)
Specify
If Financial Information is selected more information is needed
Personal Credit Card Inofrmation
Personal Finance Inofrmation
Loan Account Information
**Government Credit Card INformation
Government CC issuing bank WAS NOT notified
Other (specify below)
Specify
Select all of the following that apply to the incident
Paper Records
Record Disposal
Equipment
Email
Info Sharing
Other
Specify
If Paper Records or Record Disposal was selected provide more detail
Paper records faxed or mailed accidentally
Yes
No
NA
Paper records disposed of improperly
Yes
No
NA
Unauthorized disclosure of paper records
Yes
No
NA
Documents posted to Internet
Yes
No
NA
Documents posted to Intranet
Yes
No
NA
If Equipment was selected provide more detail
Location of equipment
Click to Select
Office
Home
Metro
Car
Other
Equipment Owner
Click to Select
Government Owned
Personally Owned
Contractor Owned
Government Equipment DAR encrypted
Click to Select
Unknown
Yes
No
NA
Government equipment password or PKI/CAC encrypted
Click to Select
Unknown
Yes
No
NA
Personal equipment commercially encrypted
Click to Select
Unknown
Yes
No
NA
Personal equipment password protected
Click to Select
Unknown
Yes
No
NA
Equipment involved # of items
Laptops
Cell Phone
MP3 player
Printer/Copier
Desktop Computer
Flash drive / removable media
External hard drive
Network intrusion
Other
If Email or Info Sharing was selected provide more detail
Email was encrypted
Yes
No
Email was digitally signed
Yes
No
Email was sent outside the DoD
Yes
No
Email recipients non-Federal agency
Yes
No
Information was
posted to the Internet
Yes
No
posted on an Intranet
Yes
No
Saved on a share drive
Yes
No
disclosed verbally
Yes
No
Investigation
Type of Investigation
Click to Select
Internal
Local Law Enforcement
Component Inspector General
DoD Inspector General
Other (specify below)
Specify
Impact Determination
Impact determination is
Low
Moderate
High
Is there an associated System of Record
Yes
No
If the answer is yes, enter the System of Record Number
Additional Notes
Enter any additional notes
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