Healthcare Cyber Incident Declaration Form
1. Organization Details
Organization Name
Contact Person
Position
Contact Email
Contact Phone
2. Incident Details
Date of Incident
Date Discovered
Type of Incident
Ransomware
Phishing
Data Breach
Malware
DDoS
Other
Description of Incident
Systems/Services Affected
Type of Data Affected
Number of Individuals/Records Impacted
3. Mitigation & Notification
Actions Taken
Authorities Notified
Has the Public Been Notified?
Yes
No