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Security incident report

To be completed within 24 hours of incident

Contact information

First name *	Last name *	Work telephone number
Title	Email

Supervisor

First name

Last name

Work telephone number

Is a statement attached?

Yes

A. Security incident information

Incident type *

Date (YYYY-MM-DD) *

Local time of Incident *

Location

Region

Office address

Incident description *

Include any events leading to or immediately following the incident (mandatory).

B. Occupational health and safety

Was anyone injured?

Yes

Was an ambulance called?

Yes

Was the person taken to the hospital?

Yes

Immediate measure taken

Indicate where the person was taken (e.g.: time of departure from the building, names of paramedics, etc.):

C. Information management

Were information or assets involved?

Yes

Security classification

Asset Type

Description of the information or assets

Paper documents, USB key, mobile device, tablet:

D. Police incident information (if applicable)

Was a police report filled?

Yes

Was police action taken?

Yes

Additional information and immediate measure taken

Indicate the information here: (Was the person arrested? What were the charges?)

Was the person arrested?

Yes

Were there charges?

Yes

Reference number

Officer first name

Officer last name

Badge number

Site-Secure

Security incident report

To be completed within 24 hours of incident