Incident Report Form

Your Name*

First

Last
Your UW Email*
Phone*
Title of Incident*
Short descriptive title of the incident (e.g., Lost laptop in dept. X).
Description*
Brief description of what happened.
Date*
Date you became aware of the situation.

MM slash DD slash YYYY
Date of Incident
Date when the incident occurred, if known.

MM slash DD slash YYYY
UW Organization*
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.
Types of Data Involved*
- An individual's first name or first initial and last name
- Social Security Number or last four digits of SSN
- Driver's license or state ID number
- Financial account number (credit, debit, etc.) and security code, access code , or password
- Full date of birth
- Private key that is unique to an individual and that is used to authenticate or sign an electronic record
- Student, military, or passport identification number
- Health insurance policy number or health insurance identification number
- Consumer's medical history, or mental or physical condition, or about a health care professional's medical diagnosis or treatment
- Biometric data generated by automatic measurements of an individual's biological characteristics, such as a fingerprint, voiceprint, eye retinas, irises, or other unique biological patterns or characteristics used to identify a specific individual
- Username or email address in combination with a password or security questions or answers that would permit access to an online account
- Don't know
- Other
Data Type - Other*
Please describe
Physical location
Where were people physically located when data were originally collected, if known (Washington State, other states, United States, and/or other countries)?
Data encryption*
Were the data encrypted, redacted, or made unusable?
- Yes
- No
- Maybe
- Don't Know
Data Systems
What system(s), if any/if known, are involved?
Research*
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.
- Yes
- No
Human Subjects Research*
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?
- Yes
- No
Institutional Review Board (IRB)
What IRB is overseeing the research?
- UW IRB
- Non-UW IRB
Reportable New Information (RNI) Number
If the incident has been reported to the UW IRB include the RNI#.
Name of Non-UW IRB
Provide the full name of the IRB without acronyms.
Reported to Others*
Have you reported the incident to other individuals? (Please limit further sharing.)
- Yes
- No
Communication processes*
Please list the names and organizations for the other individuals who have been informed about this incident.
Cause of Incident
What is the root cause of the incident, if known?
Add File
Max. file size: 15 MB.
Name
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Incident Report Form

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