BPA F 5632_01 Security Incident Report

BPA F 5632.01e

OMB

U.S. DEPARTMENT OF ENERGY
BONNEVILLE POWER ADMINISTRATION

(08-18)

SECURITY INCIDENT REPORT
SIRS Case Number:
(Security Services Use Only)

INSTRUCTIONS: A Security Incident Report (BPA F 5632.01e) is used to report security issues and criminal activity. The
completed form should be emailed to [email protected].
If loss, theft, or damage to any government property occurs during, or as a result of the incident, the property owner must submit
both a Security Incident Report and Property Loss Report (BPA F 4420.12e) in an email addressed to the following email
addresses: [email protected] and [email protected].
In addition, if the incident involves a government device capable of manipulating, sending, storing and/or receiving data the property
owner must contact the BPA Help Desk within one hour of discovery. The BPA Help Desk can be notified during normal business
hours 6 a.m. – 6 p.m. at 503-230-HELP (x4357). After hours call the Cyber Security emergency number at 503-230-5088. Follow the
phone notification with an email with both forms to [email protected].
1. Date of this
2. Date Discovered: 3. Estimated Date and Time of
4. Reported By:
5. Work Phone:
Report:
Incident:

6. Name of Facility Incident Occurred
at:

7. Specific Location (City,
State):

8. Address of Incident:

9. Police Case Number:

10. Was Local Law Enforcement Agency
Notified?
Yes
No

11. If Yes, which city was it located
in?

12. Date Notified:

13. Work Phone:

14. Was the Federal Bureau of
Investigation Notified?
Yes
No

15. If Yes, which city was it located
in?

16. Date Notified:

17. Work Phone:

18. Description of Incident (Include as much detail as possible who, what, when, where, why and how) (Use Separate sheet
if necessary):

19. Missing or Damaged Property:
There was no Government Property of any type involved in this incident.
There was Government Property involved in this incident and a Property Loss Report is attached.
20. Please list what is missing or was damaged assets not considered Personal Property (e.g., laptop bag, mouse, power code, etc.):

21. Total Estimated Cost of Incident to BPA:
22. SECURITY SERVICES COORDINATION RECORD USE ONLY
Date

Time

Date Received by NNT

Notified FPS
Called LLEA
Called FBI
Notified IG
Property Mgmt Notified
Cyber Security Notified
INFOSEC Notified
23. Comments:

FILE CODE: SS-18-15

RETENTION: NNT = 2 YRS

OMB

BPA F 5632.01e
(08-18)

Paperwork Reduction Act Burden Disclosure Statement
This data is being collected to ensure the security and safety of BPA employees, contractors, and facilities. The data you supply will be used by
security personnel for reporting any criminal vandalism, or theft of Government of personal property. Public reporting burden for this
collection of information is estimated to average .28 hours per response, including the time for reviewing instructions,
searching exiting data sources, gathering and maintaining that data needed, and completing and reviewing the collection
of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including
suggestions for reducing this burden, to Office of the Chief Information Officer, Enterprise Policy Development & Implementation
Office, IM-22, Paperwork Reduction Project (enter OMB control number), U.S. Department of Energy, 1000 Independence Ave SW,
Washington, DC, 20585-1290; and to the Office of Management and Budget (OMB), OIRA, Paperwork Reduction Project (enter OMB control
number), Washington, DC 20503.
Notwithstanding any other provision of the law, no person is required to respond to, nor shall any person be subject to a penalty
for failure to comply with a collection of information subject to the requirements of the Paperwork Reduction Act unless that
collection of information displays a currently valid OMB control number.
The Paperwork Reduction Act (PRA) of 1995 requires each Federal agency to seek and obtain approval from the Office of Management and
Budget (OMB) before undertaking a collection of information directed to 10 or more persons of the general public, including persons involved in
or supporting the operations of Government-owned, contractor-operated facilities.