1. Date/Time and duration of incident:
   
2. Is the affected system/network critical to the organization's mission?
   

   Yes

   No

   
   
3. Nature of Problem? (Check only one)
   

   Intrusion	System impairment/denial resources
   Unauthorized root access	Web site defacement
   Compromise of system integrity	Hoax
   Theft	Damage
   Unknown	Other:

   
   
4. Suspected method of intrusion/attack (check only one)
   

   Virus (provide name if known)	Vulnerability exploited (explain)
   Denial of Service	Trojan horse
   Distributed Denial of Service	Trapdoor
   Unknown	Other (Provide details in remarks)

   
   

   Remarks:

   No Remarks

   
   
5. The apparent source (IP address) of the intrusion/attack:
   
   
6. Did the intrusion/attack result in damage to system(s) or data?
   

   Yes (Provide details in remarks)

   No

   
   

   Remarks:

   No Remarks

   
   
7. What actions and/or technical mitigation have been taken?
   

   System(s) disconnected from the network	System Binaries checked
   Backup of affected system(s)	Other (Please provide details in remarks)
   Log files examined	No action(s)

   
   

   Remarks:

   No Remarks

   
   
8. In addition to being used for law enforcement or national security purposes, the intrusion-related information I reported may be shared with:
   

   The Public

   Other Law Enforcement Agencies

   
   
9. Additional Remarks: (Please limit to 500 characters. Amplifying information may be submitted separately.)
   
   No additional remarks

If the reported incident is determined to be a criminal matter you will be contacted for additional information.