DOE F 471.1 Security Incident Notification Report

DOE F 471.1
(10/2021)

OMB Control No.
1910-1800
Expires 10/31/2021

(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 exist ing data
sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. The collection of this information is mandatory to protect national
security and other critical assets entrusted to the Department. Send comments regarding this burden estimate or any other aspect of this collection of information, including
suggestions for reducing this burden, to Office of Environment, Health, Safety and Security, U.S. Department of Energy, 1000 Independence Avenue, S.W., Washington, D.C. 20585; and
to the Office of Management and Budget (OMB), Paperwork Reduction Project (1910-1800),Washington, DC 20503.

UNITED STATES DEPARTMENT OF ENERGY
OFFICE OF HEALTH, SAFETY AND SECURITY

Security Incident Notification Report
SSIMS Facility Code:
Date/Time of Incident Discovery:

Local Tracking Number:

Facility Name W here Incident Occurred:
Location (Building/Room Number):
Brief Description of the Incident:

Incident Category:

Topical Area Code:

Interest Type:

Incident Type:
 Incident has or may result in increased media attention (describe)


Incident has association with a foreign national(s)

If the incident involved classified matter, complete below items.
Classification Level of matter involved:

 Top Secret

 Secret

 Confidential

Classification Category of matter involved:

 Restricted Data

 Formerly Restricted Data

 National Security Information

Applicable Identifier(s):







W FO  SAP  SCI  FGI
 OGA
W D Sigma(s)
Naval Nuclear Propulsion Information (NNPI)
Controlled Unclassified Information (CUI)
No Foreign Dissemination

Form(s) of the matter involved:
 Electronic Storage Media
 E-mail  Inside Firewall
 Outside Firewall
 Facsimile
 Hard Copy
 Other: (describe)






Internet
Visual
Multi-media
Discussion (Audio/Verbal)
_

Point of Contact:
Name

Telephone Number

Secure Fax Number

Classification/Marking Official of this form:
Name

Telephone Number

Transmit this report via the Information Security Incident Hotline at 301-903-8116. (Use classified phone & fax, if appropriate)

Classification

DOE F 471.1
(10/2021)

Instructions for Completing the DOE F 471.1

OMB Control No.
1910-1800
Expires 10/31/2021

For all Incidents, enter the following information in the spaces provided on the DOE F 471.1:
SSIMS Facility Code

Safeguards and Security Information Management System (SSIMS) code for the location
where the incident occurred.

Date/Time of Incident Discovery

Date/time the site became aware of the incident. Format: MM/DD/YYYY, HH:MM, AM/PM;
Time Zone. If the time zone is not provided, SSIMS will default the time to 12:00 AM.

Local Tracking Number

Local site number associated with the incident, if applicable

Facility Name:

Location where the incident occurred or originated. Auto-populated on SSIMS.

Location (Building/Room Number):

The unclassified address is auto-populated on SSIMS when the Facility Code is entered.
Enter the specific location (room/building) within the facility where the incident occurred.

Brief Description of the Incident:

Provide a brief statement that describes the incident. Include information that supports the
incident category selection.

Incident Categorization:

Provide the appropriate incident category, topical area code, incident type and interest type,
if applicable.

Media Attention:

Check if the incident has or may result in increased media attention.

Foreign Nationals:

Check if the incident has association with a foreign national(s).

Classification Level of Matter Involved:

For incidents involving classified matter enter the classification level of the matter involved.

Category of Matter Involved:

For incidents involving classified matter enter the classification category of the matter
involved.

Applicable Identifier(s)

Form(s) of the Matter Involved

For incidents involving classified matter check all that apply: W ork for Others (W FO);
Special Access Program (SAP); Sensitive CompartmentalInformation (SCI), Foreign
Government Information (FGI); Other Government Agency (OGA); W eapon Data (W D). For
WD, list applicable Sigmas. Naval Nuclear Propulsion Information (NNPI), Controlled
Unclassified Information (CUI) e.g. OUOI, PII, etc, No Foreign Dissemination
For incidents involving classified matter check all that apply from the following list):

Electronic Storage Media: Includes memory devices in computers (hard drives) and any digital memory media such as USB
drives, digital memory cards, optical storage devices (CDs and DVDs), floppy diskettes, magnetic tapes, etc.
E-Mail: Any e-mail believed or verified to contain classified information that was transmitted to another computer. Indicate
whether the e-mail was sent to recipients within an internal network domain only (inside firewall), or to any combination of
recipients that includes at least one recipient with an address external to the internal network domain (outside firewall).
Facsimile: Classified information that has been transmitted across telephone lines or the Internet via a facsimile machine.
Hard Copy: Any classified information in hard copy form.
Internet: Usually websites. Indicate whether the website or file transfer site containing the classified information was available
only within an internal network domain (inside firewall), or outside the internal network domain (outside firewall).
Visual: The classified matter was not written or verbal.
Multi-Media: Classified matter produced by multiple forms of information content and information processing (e.g., text, audio,
graphics, animation, video, interactivity.
Discussion (Audio/Verbal): Classified information that is spoken/over-heard.
Other: Any form of classified matter involved in the incident that was not previously described. If selected, include a brief
description of the classified matter in the space provided.
Point of Contact:
Classification Official:

Include POC first name, last name, phone number (including area code) and secure fax
number.
Include the first name, last name, and phone number of the individual who made the
classification/marking determination of this form.