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Cybersecurity Breach Intake
Please complete the Cybersecurity Breach Intake Form.
Cybersecurity Breach Intake Form
All fields marked with an asterisk (
*
) are required.
Date of Breach
Suspected or Known
Impact of Breach
Number and type of records, etc.
Method of Breach
Hack, accidental disclosure, etc.
Information Security Program Point of Contact
First Name
Last Name
Email Address
Phone Number
School/Organization Name
OPEID
Remediation Status
(Select one)
Complete
In Process
Provide details about remediation status below
Next steps
(as needed)
Clear
Submit