250 E Street, SW

 Washington, D.C. 20525

 202-606-5000 | 800-942-2677 | TTY 800-833-3722

AmeriCorps is committed to implementing and administering a Privacy Policy that protects its employees and other 

individuals’ personally identifiable information (PII). This Breach Notification Form is available to assist in properly 

documenting a suspected or confirmed privacy breach. Please complete the form in its entirety and return 

to privacy@AmeriCorps.gov for processing. Completion of this form does not exclude you from properly notifying 

individuals impacted or following local state notification procedures.

Breach Reported by:

Name: Supervisor:

Email: Email:

Phone: Phone:

Agency/Sub-agency/Component:

Breach Overview:

Summary of the Breach:

Do not include classified information, sensitive information, or any unnecessary PII. Summarize the facts or circumstances of the theft, loss, 

or compromise of PII as currently known, including:

a. A description of the parties involved in the breach;

b. The physical or electronic storage location of the information at risk;

c. If steps were immediately taken to contain the breach;

d. Whether the breach is an isolated occurrence or a systematic problem;

e. Who conducted the investigations of the breach, if applicable; and

f. Any other pertinent information.

Date and Time of the Breach:

Location of the Breach:
AmeriCorps.gov 

Type of Breach:

Lost Information or Equipment:

Yes

No

Unauthorized Disclosure:

(e.g., email sent to incorrect address, oral or written 

disclosure to unauthorized person, disclosing documents 

publicly with sensitive information not redacted)

Yes

No

Stolen Information or Equipment:

Yes

No

Unauthorized Access:

(e.g., an unauthorized employee or contractor accesses 

information or an information system)

Yes

No

Unauthorized Equipment:

(e.g., using an unauthorized personal device, server, or 

email account to store PII)

Yes

No

Unauthorized Use:

(e.g., employee with agency-authorized access to database 

or file accesses and uses information for personal purposes 

rather than for official purposes)

Yes

No

Storage Medium:

Laptop or Tablet: Yes No Smartphone: Yes No

Desktop: Yes No Paper files: Yes No

IT System:

(e.g., Intranet/Shared Drive) Yes No Oral Disclosure: Yes No

External Storage Device:

(e.g., CD, DVD, USB Drive) Yes No

Email: 

(Provide the relevant email address, the agency, and a description of the 

e-mail server (e.g., cloud, personal, private))

Other: 

(Provide a detailed description of the medium)

Reported to US-CERT, Law Enforcement, or Congress:

Reported to US-CERT: Yes No

Reported to Law Enforcement: Yes No If any are yes, complete the following:

Reported to Congress: Yes No

Name of recipient(s):

Title of recipient(s):

Email of recipient(s):

Phone of recipient(s):

Agency and Component:

Date and Time of the Report:

Number of Individuals and Safeguards:

Number of individuals potentially affected by the breach:

Was the information unstructured:

(e.g., open fields on a form or survey) Yes No

Was the information encrypted via a NIST-validated method: Yes No

Does a duplicate set of the potentially compromised information exist: Yes No
AmeriCorps.gov 

Additional Information:

Internal breach (e.g., within the agency’s network), external, both, or unknown:

What counter measures, if any, were enabled when the breach occurred:

(List all applicable counter measures and whether each one was NIST certified (e.g., hard drive encryption on laptop, encryption of electronic files, 

password on smartphone)

What steps, if any, have already been taken to mitigate potential harm:

(e.g., calling or sending separate email(s) to recipient(s) of an unauthorized email to request deletion of original email, contacting web publishing to 

remove unredacted documents from public website)

Do you have knowledge that any information involved in the breach was intentionally stolen or misused:

(If yes, describe the basis for your knowledge and how the information may have been misused (e.g., evidence of identity theft, hacking, adverse 

publicity)

Data Elements and Information Types:

Identifying Numbers

Social Security number Truncated or Partial Social Security number

Driver’s License Number License Plate Number

DEA Registration Number File/Case ID Number

Patient ID Number Health Plan Beneficiary Number

Student ID Number Federal Student Aid Number

Passport number Alien Registration Number

DOD ID Number DOD Benefits Number

Employee Identification Number Professional License Number

Taxpayer Identification Number Business Taxpayer Identification Number (sole 

proprietor)

Credit/Debit Card Number Business Credit Card Number (sole proprietor)

Vehicle Identification Number Business Vehicle Identification Number (sole proprietor)

Personal Bank Account Number Business Bank Account Number (sole proprietor)

Personal Device Identifiers or Serial Numbers Business device identifiers or serial numbers (sole 

proprietor)

Personal Mobile Number Business Mobile Number (sole proprietor)
AmeriCorps.gov 

Biographical Information

Name (including nicknames) Gender Race

Date of Birth (Day, Month, Year) Ethnicity Nationality

Country of Birth City or County of Birth Marital Status

Citizenship Immigration Status Religion/Religious Preference

Home Address Zip Code Home Phone or Fax Number

Spouse Information Sexual Orientation Children Information

Group/Organization 

Membership Military Service Information Mother’s Maiden Name

Business Mailing Address (sole 

proprietor)

Business Phone or Fax Number 

(sole proprietor)

Global Positioning System 

(GPS)/Location Data

Personal e-mail address Business e-mail address Employment Information

Personal Financial Information 

(including loan information)

Business Financial Information 

(including loan information)

Alias (e.g., username, screenname)

Education Information Resume or curriculum vitae Professional/personal references

Biometrics/Distinguishing Features/Characteristics 

Fingerprints Palm prints Vascular scans

Retina/Iris Scans Dental Profile Scars, marks, tattoos

Hair Color Eye Color Height

Video recording Photos Voice/Audio Recording

DNA Sample or Profile Signatures Weight

Medical/Emergency Information

Physical Health Information Mental Health Information Disability Information

Workers’ Compensation 

Information Patient ID Number Emergency Contact Information 

Device Information

Device settings or preferences 

(e.g., security level, sharing options, 

ringtones)

Cell tower records (e.g., logs, user 

location, time) Network communications data

Specific Information/File Types

Taxpayer Information/Tax 

Return Information Law Enforcement Information Security Clearance/ Background Check Information

Civil/Criminal History 

Information/Police Record

Academic and Professional 

Background Information Health Information

Case files Personnel Files Credit History Information

Additional Information