NYC-WTC_000233682

NYC 9/11 Public Portal Document

RESPONSE GUIDELINES

2.4 Security Incident Report Form

INSTRUCTIONS The purpose of this form is to help organize information about a security incident, typically a security breach, which may be related to a water contamination threat. The individual who discovered the security incident, such as a security supervisor, the WUERM, or another designated individual may complete this form. This form is intended to summarize information about a security breach that may be relevant to the threat evaluation process. This form should be completed for each location where a security incident was discovered.

DISCOVERY OF SECURITY INCIDENT Date/Time security incident discovered:

Name of person who discovered security incident:

Mode of discovery: □ Alarm (building) □ Alarm (gate/fence) □ Alarm (access hatch) □ Video surveillance □ Utility staff discovery □ Citizen discovery □ Suspect confession □ Law enforcement discovery □ Other

Did anyone observe the security incident as it occurred? □ Yes □ No If “Yes”, complete the ‘Witness Account Report’ (Appendix 8.4)

SITE DESCRIPTION Site Name:

Type of facility □ Source water □ Treatment plant □ Pumpstation □ Ground storage tank □ Elevated storage tank □ Finished water reservoir □ Distribution main □ Hydrant □ Service connection □ Other

Address:

Additional Site Information:

BACKGROUND INFORMATION Have the following “normal activities” been investigated as potential causes of the security incident? □ Alarms with known and harmless causes □ Utility staff inspections □ Routine water quality sampling □ Construction or maintenance □ Contractor activity □ Other

12 Interim Final - August 2004

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NYC-WTC_000233694