Form 4000 - Informational Only.pdf

Michigan Department of Treasury 4000 (Rev. 01-19) Incident Report INSTRUCTIONS: Complete Parts 1 and 2 and immediately submit Initial Report to the Office of Privacy and Security. After incident resolution, submit Final Report (Parts 1, 2 and 3) to the Office of Privacy and Security. Refer to Procedure PT-03253, Incident Reporting and Handling.

PART 1: A. CONTACT INFORMATION (Reporting Entity) Full Name (Last, First, Middle Initial) Division/Office

Telephone Number Fax Number E-Mail Address

B. CONTACT INFORMATION (Affected Entity) Full Name (Last, First, Middle Initial) Division/Office

Telephone Number Fax Number E-Mail Address

PART 2: INCIDENT INFORMATION

Whose information was involved in the incident?

Treasury Federal Tax Information Other State Agency, specify ______________________ Other ____________________

Incident Category (select all that apply)

Passwords Shared/Stolen Computer Virus/Spam Paper Archives Compromised

Misrouted Communications Data Destruction/Deletion Safe/Lockbox/other Compromise

Unauthorized Access Backups Missing or Stolen Delivery of Documents Lost

Fraudulent Actions Hacking of Networks/Systems Inappropriate Destruction Paper

Lost/Stolen Information/Data Improperly Secured Sys/Web Inappropriate Destruction Media

Lost/Stolen Cash/Checks Circumvention of Security Protocols Lost/Stolen Equipment Inappropriate Building Access

Incident Affects Financial Information/Resources Personal Information Unauthorized/Unlawful Activity (SSN, Driver License No. Financial information) Confidential/Sensitive Information Human Resources (threat) Other ______________________________

Date Incident Occurred Time Incident Occurred Date Incident Discovered Time Incident Discovered

Incident Location Number of Individuals Affected

Involved Parties/Entities Does this involve personal information (first and last name along with a SSN, driver license number, or credit/debit card account number)?

Yes No Date of Initial Report

Description of Incident

PART 1: CONTACT INFORMATION (Affected Entity) Full Name (Last, First, Middle Initial) Division/Office

PART 3: INCIDENT RESOLUTION

4000, Page 2 Notification issued to affected individuals? How many notifications were sent? Breach Notification Method?

Yes No E-mail Telephone US Mail Web

Who was notified? Date notification was issued

Incident Cost Check if incident costs are less than $250. If $250 or more, complete the detailed summary of costs below.

Manhours: Other:

Treasury $_____________________________________________ Postage $_____________________________________________ DTMB-OES $__________________________________________ Credit Monitoring Service $_______________________________ DTMB-Treasury Agency Services $__________________________ __________________ $_________________________________

Total Cost of Incident $____________________________________

Action Taken Incident Impact

Post Incident Recommendations

PART 4: REPORT PREPARER INFORMATION

Final Report Prepared By: Date Prepared Preparer’s Title Preparer’s Telephone Number

Administrator’s Signature Date

OFFICE OF PRIVACY AND SECURITY USE ONLY

Administrator, Office of Privacy and Security Signature Date