subject_line
Data Incident Report
First Name:
*
Last Name:
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School/Building
*
Countrywood
Oakwood
Birchwood
District Office (JKAO)
Maplewood
Silas Wood
Stimson
Walt Whitman HS
Other
Date of incident:
*
+
Description of Incident:
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Loss or Theft of Media (laptop, hard drive, flash drive)
Internal Breach (Internal wrong doing)
External Breach (Hack)
Unauthorized Access to Data
Virus/Malware
Other
Other
What Information was compromised (check all that apply)
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Student Name
Student Social Security Number
Student NYSSIS ID
Student Grades
Teacher/Principal APPR Data
Other Personally Identifiable Information
Other Sensitive or Confidential Data
Was this already reported?
*
Yes
No
To whom was this reported?
*
Please describe the incident:
*
Please sign your name below:
*
clear
Date:
*
+
Email Address:
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