Integrated Safeguards and Security Management at Berkeley Lab	

Laptop and Mobile Device Loss or Theft Report

Please read this important information regarding the theft or loss of your LBNL laptop or other LBNL storage device or computer.

Your name:___________________________________________________________  
 Property#:___________   Description of Asset:_______________________________

1.	Change your passwords (personal and LBNL).  It is safe to assume that either through password caching or password notes, your passwords are potentially compromised.  You should change your institutional (LDAP, Novell, system) and personal (Bank, At Your Service) passwords as quickly as possible.  Depending on the information contained on your laptop, you might also need to change the answers to your “security questions” at non-LBNL locations (the dog’s name, etc).

Initial here
	I have taken appropriate steps to change my institutional and system passwords.	

2.	Assess whether any information contained on your system requires additional action as follows:

Personally Identifiable Information Did the device contain personally identifiable information (PII) on individuals other then yourself?    PII is:  The subject’s first name or initial, and last name, in combination with:  a)      Social Security number (SSN)  b)      Driver’s license number or State-issued Identification Card number  c)      Account number credit card number, or debit card number in combination with any required security code, access code, or password such as expiration date or “Mother’s maiden name” that could permit access to an individual’s financial account    If Yes (or maybe), Contact CPPM Immediately.  cppm@lbl.gov  
Initial here
	To the best of my knowledge, the lost device contained no personally identifiable information.  I understand that there are potential civil penalties for the unauthorized release of Private Information.	

 Personal Health Information B. Did the device contain personally identifiable health information on anyone other then yourself?  Personally identifiable health information is generally an identifying component (name, social security #, etc) with a health information component (diagnosis, treatment, research, medical history, etc).    If Yes (or maybe), Contact CPPM cppm@lbl.gov (CPPM will contact the HIPAA privacy officer)

Initial here
	To the best of my knowledge, the lost device contained no personal health information. 	

 Additional Sensitive Information
Did the device contain information of a sensitive nature to the Laboratory?  Examples: personnel records, non-public contracting information, information subject to a CRADA or Non Disclosure Agreement, sensitive security information, or material subject to attorney-client or doctor-patient privilege?   If yes, Contact CPPM cppm@lbl.gov and your line management and inform them of the type of material subject to compromise.  

Initial here
	To the best of my knowledge, the lost device contained no information of a potentially serious sensitive nature.	

If you have any questions, please contact the Computer Protection Program at cppm@lbl.gov or http://www.lbl.gov/cyber

				
Name		Signature		

Date		Employee ID		

Division