Department Of The Navy (Don) Loss Or Compromise Of Personally Identifiable Information (Pii) Breach Reporting Form

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MSG/DONCIO 291652ZFEB 2008

DEPARTMENT OF THE NAVY (DON)

LOSS OR COMPROMISE OF PERSONALLY IDENTIFIABLE INFORMATION (PII)

BREACH REPORTING FORM

This form is intended to provide information regarding the INITIAL REPORT of a loss or suspected loss of PII (i.e., a breach). As additional breach

information becomes available, this form can be submitted as often as necessary as a SUPPLEMENTAL REPORT. Select the report type from the

drop down menu above. DO NOT DELAY submission due to lack of information.

Today's Date:

US-CERT Number:

(In most cases, the US-CERT number will not be available for inclusion in

the initial report. Please provide in supplemental report, when available.)

PERSON MAKING INITIAL REPORT

2. Title:

1. Name:

3. Phone Number:

4. E-mail Address:

5. Component

(BUMED Activities should Select CNO):

6. Organization/Branch/Unit Office:

LOSS OF PII/BREACH INFORMATION

7. Date of Breach:

8. Breach Discovery Date:

9. Breach Discovery Time:

(The one hour reporting requirement to notify US-CERT begins at the Date and TIme command became aware of the breach. Use military format for time (i.e. 0930, 1455))

10. Individuals Affected by Breach:

Government Civilians:

Government Contractors:

Military (Active):

Military (Reserve):

Military (Dependent):

Military (Retired):

Members of the Public:

Other:

If Other, Specify:

Total Number of Individuals Affected by Breach:

11. Type of PII Lost