Sample It Incident Reporting Form
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1Complete form and fax to 443-926-9742 or save as PDF and email to: service.desk@maryland.gov
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IT Incident Reporting Form
Agency:
Date:
Point of Contact Name:
Phone:
Incident Details - Please provide as much information about the incident as possible.
Incident Category:
Incident Discovery Method:
Select one below:
Select one below:
Source of incident:
Select one below:
IP Address:
Port #:
Protocol:
Destination:
IP Address:
Port #:
Affected Agency System: Please provide information about your affected system and the impact to
your agency.
System Function (e.g., DNS, Web server, etc.)
Operating System:
Version:
Date of Latest Updates:
AntiVirus Installed:
Version:
Date of Latest Updates:
Briefly describe the incident including the impact to your agency.
What actions were taken to reduce the risk of this type of incident happening again?
Does your agency require any additional assistance from DoIT?
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Parent category: Business