BPA F 5632.01e Security Incident Report

BPA F 5632.01e

U.S. DEPARTMENT OF ENERGY-BONNEVILLE POWER ADMINISTRATION (BPA)

(09-19)

SECURITY INCIDENT REPORT

OMB Control Number:1910-5188
Expiration Date: 08/31/2022

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):

10. Was Local Law Enforcement Agency
Notified?
Yes
No
14. Was the Federal Bureau of
Investigation Notified?
Yes
No

8. Address of Incident:

9. Police Case Number:

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

12. Date Notified:

13. Work Phone:

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

BPA F 5632.01e

U.S. DEPARTMENT OF ENERGY-BONNEVILLE POWER ADMINISTRATION (BPA)

(09-19)

SECURITY INCIDENT REPORT

OMB Control Number:1910-5188
Expiration Date: 08/31/2022

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 OMB Control No.1910-5188, 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 OMB Control No. 1910-5188, 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.
Submission of this data is required.