Vendor / External 3rd Party Incident Reporting Form

Most form fields are required.

Contact Information

Your E-Mail Address

Organization / Company Name

Contact Information Include all applicable contact information (names, phone numbers, and email addresses).

Incident Information

Date incident was discovered?

Has the incident been confirmed as a breach?

Yes
No

Breach Information

If a breach has been confirmed please include details below, if not please answer NA::

Date / time breach was confirmed: Year / Month / Day / Hour / Minute / AM PM

Year/Month/Day Hour:MinuteAM/PM

Was personal or regulated information breached? Yes or No (if yes, please list the type of information):

Total number of individuals / records impacted:

Do any other breach compliance requirements (federal, state, industry, etc.) apply? Yes or No (if yes please explain)

Actions taken to contain / resolve breach: Please include details here.

Supplemental Information:

Additional information:

Please send any other supporting documentation to isopol@louisville.edu

Information Security Office