This form should be used for the timely reporting of cyber security incidents to Frederick County's Emergency Management.

Please provide as much information as possible. Do not copy and paste malicious code directly into this form.

First Name*

Last Name*

Job Title*

Organization*

Cell Phone

Best Contact Number

Cell Phone

Desk Phone

Desk Phone

Email Address*

Incident Details

Impacted Organization Name*

Impacted Organization Type*

Select One Fire and Rescue Law Enforcement Library Municipality School - Charter School - Public Other

Date incident detected*

Time incident detected

How was incident detected?

User Reported Endpoint Alert Firewall/IDS Log/Alert Netflow Log/Alert Phishing Platform Log/Alert User Abnormal Behavior Logs/Alert SOC Alert

Vendor Reported Penetration Test Vulnerability Scan Dark Web Discovery Other (explain below) I don't know

Incident Type?

Denial of Service Malware Man-in-the Middle Phishing Insider Threat

Account Compromise Privilege Escalation Other Unknown

Incident Status*

Select One On-going Resolved Unknown

Incident is*

Confirmed Suspected

Brief description of incident. Include any observations, impact to business, and any actions taken.

Actual or potential impact to life-safety or critical infrastructure systems?*

Select One Yes No Unknown

If yes, list systems:

Who has been notified?

CISA CSIRT Insurance Law Enforcement

Legal Counsel MCAC Public Unknown

What is your ability to recover from the incident?*

Select One Normal - Predictable with existing resources. Supplemented - Predictable; requires additional resources. Extended - Unpredictable; requires additional resources and external assistance. Not recoverable. Unknown

Additional information. Include any requests for assistance and the type of assistance requested.