Exhibit A-7.1 Form 4000 Incident Report.pdf

This is an Incident Report Form 4000 issued by the Michigan Department of Treasury, designed to document and track incidents involving sensitive information and resources. The form serves as a standardized reporting mechanism for entities handling Treasury data, Federal Tax Information, and other confidential materials. The form does not specify products, services, quantities, response dates, or contract terms, as it functions as an internal incident documentation tool rather than a procurement solicitation.

The form requires comprehensive incident tracking including contact information for reporting entities, detailed incident categorization across multiple incident types such as misrouted communications, data destruction, document delivery issues, and inappropriate destruction of paper or media records. Reporting requirements include specific dates and times of incident occurrence and discovery, location information, involved parties, initial report dates, and a detailed incident description. The form mandates documentation of incident resolution methods including email, telephone, and web-based communications, quantification of incident costs broken down by manhours and other expenses, assessment of incident impact, and post-incident recommendations. The Office of Privacy and Security maintains final oversight authority with designated sections for report preparer information including name, title, telephone number, and preparation date.