DOE F 5639.3 Report of Security Incident/Infraction

DOE F 5639.3
(10/2021)
All Other Editions Are Obsolete

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

U.S. DEPARTMENT OF ENERGY

REPORT OF SECURITY INCIDENT/INFRACTION

OMB BURDEN DISCLOSURE STATEMENT
Public reporting burden for this collection of information is estimated to average 25 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. 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.

Part I - NOTIFICATION OF SECURITY INCIDENT

Part I. To be completed by the Security Office conducting the preliminary inquiry.
1.

Organization in which incident occurred:

3.

Nature of incident:

4.

Classification level of information involved:
Confidential
Secret
Top Secret

7.

2.

5.

Date of incident:

Category of information involved:

6.

Restricted Data
Formerly Restricted Data
National Security Information

Identify other caveats of
information involved:

Details of incident:

8. Name, title, and organization of the individual
reporting the security incident:

9. Signature:

10. Date

PRIVACY ACT STATEMENT ON REVERSE

DOE F 5639.3
(10/2021)
All Other Editions Are Obsolete

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

PART II – REPORT BY OFFICE CONCERNED

To be completed by the Office in which incident occurred/originated and return within
15 days to the Cognizant Security Office of the individual receiving infraction.
1.

Reason or cause of incident:

2.

Name and title of person responsible
for infraction:

3.

5.

Signature of individual receiving infraction:

7.

Correction action taken, to include disciplinary action, if applicable.

8.

Name and title of Office Director:

9.

Social Security Number:

Signature:

4.

Number of infractions incurred in the
last 12 months:

6.

Date

10. Date:

PRIVACY ACT STATEMENT
Executive Order 12356, Part 5, dated April 2, 1982, authorizes collection of this information. The primary use of this information is by the Office of
Environment, Health, Safety and Security for documenting security incidents and infractions. The information contained on this form may be disclosed as a routine
use to the appropriate agency, whether Federal, State, local or foreign, charged with the responsibility of investigating or prosecuting such incident or charged
with enforcing or implementing the statute, or rule, regulation, or order issued pursuant thereto. Information on this form may be disclosed as a routine use to a
Federal agency in response to its request in connection with the hiring or retention of an employee, or the issuance of a security clearance. The collection of the
employee’s Social Security Number is authorized by Executive Order 12356, Part 5. The collection of this information is mandatory to protect national security and
other critical assets entrusted to the Department. `