Form NCUA Cyber Incident Notification

NATIONAL CREDIT UNION ADMINISTRATION
CYBER INCIDENT NOTIFICATION
New or Modified Incident
Is this a new, updated, or corrected cyber incident report?
New

If the incident is an update or correction, provide the incident ticket number below:
Individual Reporting Incident
Individual's Name
Email Address
Phone Number
Preferred Method of Contact:
Email
Phone
Credit Union Information
Credit Union Name
Charter Number
Credit Union Address
City
State
Postal Code
Cyber Incident Point of Contact
Point of Contact's Name
Email Address
Phone Number
Preferred Method of Contact:
Email
Phone
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Cyber Incident Information
1. Date Incident Was Detected
2. Date Incident Occurred
3. Date Incident Reported to NCUA

4. Was law enforcement or another federal or state agency notified?
Name of Agency:
Date of Notification:
5. Brief Description of Incident
6. Services Impacted
7. Where is this service managed?

8. Was this caused by a third-party?
If yes, name of third party:
If applicable, name of product or service:
9. Operational Impact
10. Functional Impact
11. Informational Impact
12. Was PII Accessed?
13. Was PII Compromised or Stolen?
If yes, number of members affected, if known.
14. Recoverability of Incident

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15. Indicators of Compromise
Please provide any indicators of compromise, if known
16. Common Vulnerabilities and Exposure Identifier (CVE-ID)
Please provide any CVE-IDs, if known. Do not include the CVE prefix (e.g., 2014-7654321)

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PRIVACY NOTICE: The information you provide will be used to track and manage reported
cyber incidents. The NCUA securely maintains all personally identifiable information stored in
CICURS and only shares it outside of the NCUA if required by law or regulation. For additional
information, please contact [email protected].
PAPERWORK REDUCTION ACT STATEMENT: According to the Paperwork Reduction
Act of 1995, no persons are required to respond to a collection of information unless it displays a
valid OMB control number. Comments concerning the accuracy of the burden estimate or any
other aspect of this collection of information, including suggestions for reducing this burden,
should be addressed to the National Credit Union Administration, ATTN: PRA Clearance
Officer. OGC, 1775 Duke Street, Alexandria, Virginia 22314. This collection is approved under
OMB Control Number 3133-0033

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