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Confidential Information-Data Loss or Breach of Security Incident Report This form is used to document a suspected theft or loss of student, staff or faculty confidential information at Shawnee State University. Shawnee State offers a comprehensive definition of student, staff or faculty information residing on university or personally-owned storage devices that is considered confidential in nature, in the UTAC-approved Conditions for Network and Computer Use document. Information submitted on this form will be forwarded to the Director of UIS for evaluation. It may also be shared with other SSU employees charged with the task of identifying SSU’s responsibility for notification to impacted individuals under state or federal law, in cases of confirmed loss or theft of confidential data. Reporting suspected violations of the Conditions for Information Security is the responsibility of all members of the University community. If you suspect that SSU confidential information has been lost or stolen, please complete the inquiry below to the best of your knowledge and submit the form.


Point of Contact (POC) information
Name:	Job Title:	Dept:

Work Phone:	Cell Phone:	Email:

Report Date: Time:

Location of Incident:

Nature of Incident:

Description of Incident:


Description of Confidential Information:


Information Format: Electronic Paper

Location of File:
(BE SPECIFIC. For example, your PC or laptop's hard drive (include path (ex. C:\Document and Settings\...), file cabinet, etc)

Was Data Transmitted Electronically Offsite: Yes No Unknown

Electronic Data Format: Spreadsheet Database Word Document Email Other

Electronic Media Format: CD/DVD Hard Drive Floppy External Storage Device USB Drive Mobile Storage Device Tape Disk

Data Accessibility: Encrypted Unencrypted Redacted Unknown

Is Unauthorized Access to Data Currently Possible: Yes No Unknown

Missing Hardware Identified: Yes No Unknown

Hardware Type: Laptop Desktop PDA USB Storage Other Storage

Hardware Manufacture: IBM Dell HP Gateway Other

Hardware Model Number: Hardware Model Name:

Is Hardware Owned by SSU: Yes No

Is Unauthorized Access to Hardware Currently Possible: Yes No Unknown

Other Individuals Currently Aware of Incident:

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This page maintained by Leigh Gerlach

Shawnee State University
940 Second Street
Portsmouth, Ohio 45662-4344
To_SSU@shawnee.edu
740.351.4SSU
TTY: 740.351.3159

Last Updated:
02.08.2008 09:04 AM