Event and Incident Reporting Form

Event and Incident Reporting Form

By completing and submitting this form, you are fulfilling the statutory requirements noted in sections 282.318 and 282.3185, F.S., to report cyber security events and incidents to Florida Digital Service (FL[DS]) and the Florida Department of Law Enforcement (FDLE), Cybercrime Office.

This information is confidential and exempt from public record pursuant to F.S. 119.0725.

Entity Type*

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Entity Name*

Select

Entity Name*

Select

Entity Name*

Select

Entity Name*

Select

Entity Name*

Select

Entity Name*

Primary Contact Name*

Primary Contact Phone*

Phone

Primary Contact Email

Primary Contact Title/Role

Alternate Contact Name

Alternate Contact Phone

Phone

Alternate Contact Email

Incident Summary

Incident Observed Date

Incident Observed Time

Format: HH:MM (Example: 5:30pm = 17:30)

Incident Level*

Select

Is ransomware involved?*

Select

Incident Type*

Select all that apply.

Select

Incident Description*

Does this event/incident impact any of the following?*

Select all that apply.

Critical Infrastructure

Emergency Operations

Emergency Communications

None of the Above

Malicious IP Addresses and Other Indicators of Compromise (IOCs)

Scope

System Type/Function

Indicate known system characteristics like platform, operating system, and business function.

Location of Affected System(s)

If physical, indicate data center name/on-prem location. If virtual, indicate cloud/SaaS provider.

Other Scope Information

Data and Fiscal Impact

Data Type(s) Affected*

Do Backups Exist for Affected System(s)?

Select

Date of Most Recent Backup*

Physical Location of Backup

Backup Affected?*

Yes

Backup Created Using Cloud-Computing?*

Yes

Estimated Fiscal Impact*

Details of Ransom Demanded (if applicable)*

Do you require assistance with this event or incident?*

Your response is not binding. If you decline assistance now, you can still request it later if needed.

Select

Send me a copy of my responses

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