0917-F07-02b Incident response form

INCIDENT REPORTING FORM

Form Approved
OMB No. 0917-0036
Exp. Date 07/31/2018

Important: Initial notification must be exclusively made to the IHS Incident Response Team (IRT) no
later than 30 minutes from discovery. All incidents must also have a resolution completed.
Contact the IHS IRT: Email: IRT@ihs.gov; Business Hours: 1-888-830-7280 (OIT Help Desk).
After Hours: 702-562-8201 (NOSC).
Check One:

Incident Notification

Update

Resolution

IR Primary Handler:
Does the incident involve Personally Identifiable Information (PII)?

Yes

No (if yes, complete PII box)

KEY INFORMATION
Date/Time of Incident Discovery:

Date/Time Incident Occurred:

Facility name:

Discoverer of incident:

Contact person and contact information:

Alternate contact and contact information:

INCIDENT SUMMARY

Form F07-02b, related to SOP07-02

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Version 1.5 - 1/2015

INCIDENT REPORTING FORM

DETAILED INCIDENT DESCRIPTION

INCIDENT MITIGATION

PERSONALLY IDENTIFIABLE INFORMATION (PII)

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it
displays a valid OMB control number. The valid OMB control number for this information collection is 0917-0036. The time
required to complete this information collection is estimated to average 15 minutes per response, including the time to review
instructions, search existing data resources, gather the data needed, to review and complete the information collection. If you
have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: Indian
Health Service, 5600 Fishers Lane, Rockville, MD 20857, Attention: Information Collections Clearance Officer.

Form F07-02b, related to SOP07-02

2 of 2

Version 1.5 - 1/2015