Form Pi 2 - Irs Office Of Safeguards - Data Incident Report
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1STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
IRS OFFICE OF SAFEGUARDS
DATA INCIDENT REPORT
(for federal tax information only)
Contact Information
AGENCY NAME:
AGENCY ADDRESS:
CONTACT NAME:
PHONE #:
EMAIL ADDRESS:
Incident Information
DATE INCIDENT O
URRED:
DATE INCIDENT DIS OVERED:
TIME INCIDENT O
URRED:
TIME INCIDENT DIS OVERED:
DESCRIPTION OF INCIDENT DISCOVERY:
ADDRESS WHERE INCIDENT OCCURRED:
DESCRIPTION OF INCIDENT:
DATA INVOLVED (INCLUDE SPECIFIC ELEMENTS IF KNOWN)
# OF FTI RECORDS AFFECTED:
SPECIFIC TECHNOLOGY INVOLVED (E.G., LAPTOP, SERVER, MAINFRAME)
Incident Response Information (Safeguards Use Only)
REPORT DATE:
REPORT TIME:
PI 2 (6/15) (IRS DATA INCIDENT REPORT) REQUIRED FORM - NO SUBSTITUTE PERMITTED
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