--- generated_by: surveylegend-page-markdown title: Security Incident Report Form Template | SurveyLegend description: Collect a safe initial description of a suspected digital security incident. Adapt seven report fields and your escalation instructions in SurveyLegend. canonical: https://www.surveylegend.com/survey-examples-templates/technology-digital-experience-surveys/security-breach-report-template/ --- # Suspected Security Incident Report Form Template Make it easier to describe a digital security concern without requiring a technical diagnosis. Adapt these seven initial report fields and your organization's real reporting instructions in SurveyLegend. [Try this template ](https://app.surveylegend.com/register/)[Preview template](https://www.surveylegend.com/survey-examples-templates/technology-digital-experience-surveys/security-breach-report-template/#try-template) Preview on a device Show the desktop survey layout Show the tablet survey layout Show the mobile survey layout ![](https://www.surveylegend.com/survey-template-media/demo-backgrounds/security-breach-report-template-background.avif) **SurveyLegend** 1 / 7 Suspected Security Incident Report Form When did you first notice the concern? Include date, approximate time, and time zone if known. Your answer… Next → Suspected Security Incident Report Form [Preview](https://www.surveylegend.com/survey-examples-templates/technology-digital-experience-surveys/security-breach-report-template/#try-template) Share [Facebook ](https://www.facebook.com/sharer/sharer.php?u=https%3A%2F%2Fwww.surveylegend.com%2Fsurvey-examples-templates%2Ftechnology-digital-experience-surveys%2Fsecurity-breach-report-template%2F)[LinkedIn ](https://www.linkedin.com/sharing/share-offsite/?url=https%3A%2F%2Fwww.surveylegend.com%2Fsurvey-examples-templates%2Ftechnology-digital-experience-surveys%2Fsecurity-breach-report-template%2F)[X ](https://x.com/intent/tweet?url=https%3A%2F%2Fwww.surveylegend.com%2Fsurvey-examples-templates%2Ftechnology-digital-experience-surveys%2Fsecurity-breach-report-template%2F\&text=Suspected%20Security%20Incident%20Report%20Form%20Template)[Reddit](https://www.reddit.com/submit?url=https%3A%2F%2Fwww.surveylegend.com%2Fsurvey-examples-templates%2Ftechnology-digital-experience-surveys%2Fsecurity-breach-report-template%2F\&title=Suspected%20Security%20Incident%20Report%20Form%20Template) Make it easier to describe a digital security concern without requiring a technical diagnosis. Adapt these seven initial report fields and your organization's real reporting instructions in SurveyLegend. A suspicious message does not automatically mean a breach occurred. A reporter should be able to explain what they saw and which service was involved while the designated security team determines the next step. ## When to Use This Template Use this as an initial notification only after your security team approves the collection channel, access controls, and monitoring process. For ordinary product questions without a security concern, use a separate [support request form ](https://www.surveylegend.com/survey-examples-templates/web-forms-questionnaires/support-request-form-template/). An active urgent incident must follow the organization's established escalation route. **Create your suspected security incident report form in SurveyLegend** A suspicious message does not automatically mean a breach occurred. A reporter should be able to explain what they saw and which service was involved while the designated security team determines the next step. ## 7 Suspected Security Incident Report Form Questions Report one suspected digital security concern using general descriptions. You do not need to confirm a breach. Do not include passwords, access codes, customer data, full message contents, suspicious clickable links or files. Every field is optional. Use the organization's stated urgent reporting route if immediate attention is needed; this form alone does not guarantee a response. Try the survey ## A little feedback. A clearer picture. Explore this 7-question example at your own pace. Every question is optional. Preview on a device Show the survey at full desktop width Resize the survey to a tablet-width preview Resize the survey to a mobile preview with scrolling inside the frame Choose a look Use Classic: a white survey card over the background photo Use Light: dark text over a light tint covering the background photo Use Dark: light text over a dark tint covering the background photo SurveyLegend demo Question 1 of 7 ### Suspected Security Incident Report Form 01 When did you first notice the concern? Include date, approximate time, and time zone if known. Share your answer, or skip this question. 02 Which kind of concern best describes what you noticed? Choose one answer, or skip this question. Suspicious email or message Unexpected sign-in or account activity Lost work device Unexpected access to information Unusual device or application behavior Another concern Not sure 03 Which work service or device type appears to be involved? Use a general name, not credentials or a full technical address. Share your answer, or skip this question. 04 What did you personally observe? Describe it briefly without copying private content, links, or files. Share your answer, or skip this question. 05 What action, if any, had you already taken before making this report? Choose one answer, or skip this question. No action yet Used the organization's reporting button or route Opened a message or link Entered information in response to a message Contacted IT or security separately Another action Prefer not to answer 06 Is the concerning activity still visible to you? Choose one answer, or skip this question. Yes No Not sure Cannot safely check Prefer not to answer 07 What approved work contact can the security team use to follow up with you? Share your answer, or skip this question. #### One last look Review your answers before submitting this demo. 0 answered #### Thank you for trying the survey! You’ve tried the template from the respondent’s side. Make it your own with SurveyLegend. [Create your own survey](https://www.surveylegend.com/register/) Checking submission availability… This is a demo. We count starts and submissions only. Your answers stay in your browser and are never sent or saved. **—**Starts **—**Submissions Activity is temporarily unavailable. ## How to Adapt the Questionnaire Replace the escalation note with the verified, monitored route your organization actually uses. State who receives reports, the real monitoring hours, and a fallback if the usual account or device is affected. Keep no-upload instructions prominent. The form must not invite passwords or technical evidence dumps. Tell reporters that 'not sure' is acceptable, and obtain security-team review before using a survey platform for real incident notifications. ## When to Ask Make the approved route easy to find before an incident occurs. Encourage prompt use according to the organization's process, without asking people to investigate first. A public template demo is only a demonstration and does not notify a security team. ## How to Use the Responses Treat each response as an unverified report. The authorized team should review observation time, affected service, observed behavior and actions already taken together, then use the established incident process. Do not auto-label an employee careless, infer the scale of a breach from one report, or treat a submission counter as incident prevalence. Keep case status, technical evidence and response actions in the approved incident-management system. Document how follow-up will occur when contact information is missing. ## What the Research Adds Burda, Allodi, Serebrenik, and Zannone's 2024 university case study interviewed 49 employees who had reported phishing emails and identified “13 main themes driving reporting motivations.” It highlights reporting as a human process to understand, rather than assuming a policy guarantees participation. Its reporter-only sample does not validate this form or prove it increases reporting. The study covers phishing, not every incident type listed here. Read the [phishing reporting study ](https://research.tue.nl/en/publications/protect-and-fight-back-a-case-study-on-user-motivations-to-report/). ## Frequently asked questions ### Does this establish that a breach happened? No. The form records an observation for qualified review. A suspicious event and a confirmed breach are different conclusions. ### Should someone attach the suspicious file? Not through this template. Use the security team's separately approved evidence-transfer process if requested; the initial form deliberately excludes files and sensitive contents. ### Is the public demo an incident reporting service? No. Demo answers stay in browser memory and are not sent to a security team. Organizations must establish and test their own reporting process before real use. ## Printable Suspected Security Incident Report Form Provide all seven fields with ample space for a brief non-sensitive observation. Print the approved urgent route and no-secrets/no-files instruction at the top. Store and deliver completed paper forms only through the security team's approved process. Paper responses need separate review or manual entry; they are not automatically added to online results. ![First page of the printable Suspected Security Incident Report Form Template with questions and answer spaces](https://www.surveylegend.com/survey-template-media/pdf-previews/security-breach-report-template-pdf-preview.avif) [![](https://www.surveylegend.com/user-guide-media/icons/download-pdf.svg) Download the questionnaire](https://www.surveylegend.com/downloads/survey-templates/suspected-security-incident-report-form-template.pdf) Export Suspected Security Incident Report Form as PDF ## AI Prompt: Suspected Security Incident Report Form Copy this suspected security incident report form prompt into an AI assistant to prepare the questionnaire. Review the result, then build and customize it in SurveyLegend. It does not automatically create or transfer a survey. ## Suspected Security Incident Report Form Prompt AI Prompt: Suspected Security Incident Report Form [Create this survey in SurveyLegend](https://www.surveylegend.com/register/) Copy the prompt into an AI assistant to draft the questions, then build your survey in SurveyLegend. [Sign in](https://app.surveylegend.com/) to SurveyLegend to build your suspected security incident report form Technology & Digital Experience Survey Templates 1. [![Preview of the Website Feedback Survey demo showing its first question and answer options](https://www.surveylegend.com/survey-template-media/previews/website-feedback-demo-preview.avif) Website Feedback Survey Template Technology & digital experience This website feedback survey template helps you learn why visitors came to your website, whether they completed their task, and what got in the way. Its six questions cover the visit’s purpose, outcome, and difficulties. 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