DOE-F-471.1 US Department of Energy Office of Safeguards and Securit

DOE F 471.1

OMB Control Number

(06-99)

1910-1800

(Classification)
OMB Burden Disclosure Statement
Public reporting burden for this collection of information is estimated to average 10 (minutes) per response, including the time for reviewing instructions, searching existing data sources,
gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this estimate or any other aspect of this information, including
suggestions for reducing this burden, to Information, Records, and Resource Management, MA-41-GTN, Paperwork Reduction Project (1910-1800), U.S. Department of Energy, Washington, DC
20874-1290; and to the Office of Management and Budget (OMB), Paperwork Reduction Project (1910-1800), Washington, DC 20503.

UNITED STATES DEPARTMENT OF ENERGY
OFFICE OF SAFEGUARDS AND SECURITY

Security Incident Notification Report
Date/Time of Incident Discovery:

Classification Level:

TOP SECRET

SECRET

CONFIDENTIAL

Category of Information Involved:

RD

FRD

NSI

Applicable Identifier (s):

WD

WFO

SAP

FGI

OGA

Facility/Location of Incident:

Form(s) of the Information Involved:
Magnetic Media

Internet

Discussion

Fascimile

Hard Copy

Visual

Multimedia

E-Mail

Other

Brief Description of the Incident:

Point of Contact:
Name

Telephone Number

Secure Fax Number

Transmit this report via the Information Security Incident Hotline at (301) 903-8116. (Classified phone & fax)

(Classification)