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      • Incident Report Form






  • Short descriptive title of the incident (e.g., Lost laptop in dept. X).
  • Brief description of what happened.
  • Date you became aware of the situation.

    MM slash DD slash YYYY

  • Date when the incident occurred, if known.

    MM slash DD slash YYYY

  • UW organization where the incident occurred or was observed, if known.

    We are using the Institutional Organization Structure (IOS) to help manage information about incidents. If interested, you can learn more about the IOS by reviewing this paper by the Data Governance Committee.

    IOS Level 1 is the University of Washington.







     













  • Please describe
  • Where were people physically located when data were originally collected, if known (Washington State, other states, United States, and/or other countries)?
  • Were the data encrypted, redacted, or made unusable?




  • What system(s), if any/if known, are involved?
  • Does the incident involve research? Research is defined as a systematic investigation designed to develop or contribute to generalizable knowledge, and may include research development, testing, and evaluation.


  • Does the incident involve human subjects? Human subjects are defined as living individuals about whom an investigator (whether professional or student) is conducting research: (i) obtains information or biospecimens through intervention or interaction with the individual, and uses, studies, or analyses the information or biospecimens, or (ii) obtains, uses, studies, analyzes, or generates identifiable private information or identifiable biospecimens?


  • What IRB is overseeing the research?


  • If the incident has been reported to the UW IRB include the RNI#.
  • Provide the full name of the IRB without acronyms.
  • Have you reported the incident to other individuals? (Please limit further sharing.)


  • Please list the names and organizations for the other individuals who have been informed about this incident.
  • What is the root cause of the incident, if known?
  • Max. file size: 15 MB.

  • This field is for validation purposes and should be left unchanged.






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      • Incident Report Form
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