US-CERT Incident Reporting System
MY CONTACT INFORMATION
Please provide your contact information so that we are able to contact you should we need to follow-up. Your contact information is not required to submit a report using this form. However, incomplete contact information may limit US-CERT's ability to process or act on your report.
IMPACTED USER'S CONTACT INFORMATION
RECOVERY FROM INCIDENT
Does your agency currently consider this to be a breach that must be reported to Congress within 30 days in accordance with OMB guidance? * Required
Privacy Act Statement
Authority: 5 U.S.C. § 301 and 44 U.S.C. § 3101 authorize the collection of this information.
Purpose: The primary purpose for the collection of this information is to allow the Department of Homeland Security to contact you about your request.
Routine Uses: The information collected may be disclosed as generally permitted under 5 U.S.C. § 552a(b) of the Privacy Act of 1974, as amended. This includes using the information as necessary and authorized by the routine uses published in DHS/ALL-002 - Department of Homeland Security (DHS) Mailing and Other Lists System November 25, 2008, 73 FR 71659.
Disclosure: Providing this information is voluntary. However, failure to provide this information will prevent DHS from contacting you in the event there are questions about your request.