DOE F 5639.3
(12-93)
(Formerly DOE F 5630.13)
All Other Editions Are Obsolete
OMB Control No.
1910-1800
U.S. DEPARTMENT OF ENERGY
REPORT OF SECURITY INCIDENT/INFRACTION
OMB BURDEN DISCLOSURE STATEMENT
Public reporting burden for this collection of information is estimated to average 25 minutes per response, including the time for reviewing
instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information.
Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to
Office of Information Resources Management Policy, Plans, and Oversight, Records Management Division, HR-422 - GTN, Paperwork Reduction
Project (1910-1800), U.S. Department of Energy, 1000 Independence Avenue, S.W., Washington, DC 20585; and to the Office of Management and
Budget (OMB), Paperwork Reduction Project (1910-1800), Washington, DC 20503.
Part I - NOTIFICATION OF SECURITY INCIDENT
Part I. To be completed by the Security Office conducting the preliminary inquiry.
1. Organization in which incident occurred:
2. Date of incident:
3. Nature of incident:
4. Classification level of information involved: 5. Category of information involved:
6. Identify other caveats of
information involved:
7. Details of incident:
PRIVACY ACT STATEMENT ON REVERSE
8. Name, title, and organization of the individual
reporting the security incident:
9. Signature: 10. Date:
Restricted Data
Formerly Restricted Data
National Security Information
Confidential
Secret
Top Secret
Printed with soy ink on recycled paper
