Incident Reporting Form
I am: the effected entity reporting incident affecting other entity
Contact Information of the Reporter
Name & Role/Title Radhanandu & Chef / Radhas Recipe (Facebook ad account Individual Organization
Organization name (if any)
Contact No. 8667611773 / 7904725500 / 8438342299 Email:
[email protected]Address: 38, Ganesh Nagar, New Vellanur, Avadi,
Thiruvallur: 600062
Basic Incident Details
Affected entity
(if not same as reporting entity above)
Incident Type
Targeted scanning/probing of critical Data Breach Attacks or malicious/suspicious activities
networks/systems Data Leak affecting systems/ servers/ networks/
Compromise of critical systems/information Attacks on Internet of Things (IoT) devices software/ applications related to Big Data,
Unauthorised access of IT systems/data and associated systems, networks, Block chain, virtual assets, virtual asset
software, servers exchanges, custodian wallets, Robotics, 3D
Defacement or intrusion into the website
Attacks or incident affecting Digital and 4D Printing, additive manufacturing,
Malicious code attacks
Payment systems Drones
Attack on servers such as Database, Mail and DNS
and network devices such as Routers Attacks through Malicious mobile Apps Attacks or malicious/ suspicious activities
Fake mobile Apps affecting systems/ servers/software/
Identity Theft, spoofing and phishing attacks
Unauthorised access to social media applications related to Artificial Intelligence
DoS/DDoS attacks and Machine Learning
accounts
Attacks on Critical infrastructure, SCADA and
Attacks or malicious/ suspicious activities Other (Please Specify)
operational technology systems and Wireless
networks affecting Cloud computing
----------------------------------------------------------
systems/servers/software/applications
Attacks on Application such as E-Governance, E-
Commerce etc. ----------------------------------------------------------
Is the affected system/network critical to
the organization’s mission? (Yes / No).
(Brief details.)
Basic Information of Affected System Domain/URL:
(Provide information that is readily IP Address:
available.) Operating System:
Make/ Model/Cloud details:
Affected Application details (If any):
Location of affected system (including City, Region & Country):
Network and name of ISP:
Brief description of Incident: Occurrence date & time (dd/mm/yyyy hh:mm):
Detection date & time (dd/mm/yyyy hh:mm):
Note: (i) This form provides general guidance in terms of information which could be relevant to the incident.
(ii) It is not mandatory to fill and/or sign this form. Incidents may also be reported by providing relevant information in the communication
itself or in any other readable form.
(iii) Reporting entity may, if desired, also provide relevant information other than mentioned in this form.
Mail/Fax incident reports to: CERT-In, Electronics Niketan, CGO Complex, New Delhi 110003 Fax:+91-11-24368546 or email at: [email protected]
