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Incident Report - Real Estate Sector

** Critical Infrastructure Information

Express Statement to the Federal Government: This information is voluntarily submitted to the federal government in expectation of protection from disclosure as provided by provisions of the Critical Infrastructure Information Act of 2002.

In order to be considered for qualification as "protected," the information must be voluntarily submitted for use by the Department of Homeland Security (DHS) for the security of critical infrastructure, must be accompanied by the notice printed at the top of this form (the "Express Statement") and the certification printed at the bottom of this form, and cannot be information that is otherwise required to be submitted to the government.

Incident Report – Real Estate Sector

** CRITICAL INFRASTRUCTURE INFORMATION **

Express Statement to the Federal Government: This information is voluntarily submitted to the federal government in expectation of protection from disclosure as provided by provisions of the Critical Infrastructure Information Act of 2002.

In order to be considered for qualification as "protected," the information must be voluntarily submitted for use by the Department of Homeland Security (DHS) for the security of critical infrastructure, must be accompanied by the notice printed at the top of this form (the "Express Statement") and the certification printed at the bottom of this form, and cannot be information that is otherwise required to be submitted to the government.
 

  Section I – Report Origination Information
 
 

Please complete either Part A or Part B, as appropriate.

PART A: FIRST-TIME REPORT OF AN INCIDENT
Based on the information you provide here, a reference number for this report will be automatically generated below. Please note this number
for future use.

Today's Date:

Street number of property:
(For example, if the building is located at 12402 Main Street, enter 12402; if the building is located at One Main Center, enter 1; or if the property has no numeric address, such as Main Street Center, enter 10.)

City in which property is located:

Zip code of property:

Incident Report reference number
(generated by the system):

PART B: FOLLOW-UP REPORT ON AN INCIDENT

Today's Date:

If you are submitting additional information about an incident or series of incidents already reported to DHS, enter the reference number of the initial report here:
 
  Your Contact Information
  Name
  Title
  Organization
  Street Address
  City
  State
  Zip
  Telephone
  Fax
  Email
 
  Security Director for the Property or Your Organization
(if not the same person as above)
  Name
  Title
  Organization
  Street Address
  City
  State
  Zip
  Telephone
  Fax
  Email
 
Section II – Basic Property Information
 
  Please select all that apply relative to the specific property this report is about:
  Lodging
  Under 100 guest rooms
  Over 100 guest rooms
  Luxury/Upscale
  Budget
 
  Multi-housing
  High-rise
  Garden/Low-rise
  Under 100 living units
  Over 100 living units
  Luxury/Upscale
  “Affordable”/Low-income
 
  Office
  Class A
  Class B
  Class C
 
  Industrial
 
  Retail
  Shopping mall
  Shopping center
  Local
  Regional/Super-regional
  Mega-regional/National destination center
 
  Other property type (please explain):
 
 
  If office, industrial or retail, what is the approximate size of the building:
  Under 100,000 sf
  101,000-500,000 sf
  501,000-1,000,000 sf
  Over 1,000,000 sf
 
  Iconic/landmark
 
Section III – Incident Information
 
  Date the incident occurred:
(If the incident occurred over a period of time, please note the date the incident began, or an approximate date.)
 
 
  Exact or approximate local time the incident occurred:
 
 
  Incident Thresholds Satisfied (for All Property Types)
(Check All that Apply)
  Intelligence gathering/Suspicious surveillance
  Terror/Bomb threats
  Unauthorized access
  Public health/HVAC incidents
  Thwarted terrorist attacks
  Suspicious mail/Delivered package contamination
  Extended service outage (water, electrical, telecommunications)
  Official threat warning from local authorities
  Suspected arson
  Discovery or appearance of suspicious bomb-making materials
 
  Additional Lodging-Specific Thresholds
  Suspicious items found in rooms
  Suspicious food-poisoning incidents affecting multiple guests
  Suspicious behavior by guests
  Suspicious telecommunications or Internet activity
  Suspicious bookings
 
  Additional Multi-Housing Specific Thresholds
  Suspicious behavior of residents or guests
  Suspicious behavior of applicants for residency
  Suspicious items found in residential units
 
  Additional Retail-Specific Thresholds
  Suspicious thefts
  Food court poisoning incidents affecting multiple people
  Suspicion of "front companies"
 
  Briefly describe the incident:
 
 
Section IV – Local Authorities Notification
 
  Date that local police or regional FBI officials were initially notified of the incident:
 
 
  Describe their response (if any):
 
   
  Name of the local, state or regional law-enforcement official most familiar
with the incident (if known):
 
  Contact telephone number for that person:
 
 
Section V – Additional Information about the Property (OPTIONAL)
 
  Please select all that apply relative to the specific property this report is about:
  Construction type:
  Precast
  Brick
  Wood
  Other
 
 
  Location:
  Urban/Central business district
  Urban/Other
  Suburban
  Rural
 
  Number of stories:
  Less than 5
  5-15
  16-50
  51 or more
 
  Approximate age of facility:
  Less than 15 years old
  16-30 years old
  31-50 years old
  51 or more years old
 
  Parking facility configuration (if applicable):
  Attached garage
  Service lot
  Underground
  Single level
  Multiple levels
 
  Is the property freeway accessible?
  Yes
  No
 
  Are there any “sensitive” users or occupants in the property?
  Diplomat/Foreign agencies or offices
  Military or national security agencies or offices
  Other government agencies or offices
  High-profile institutions, groups or individuals
  Media outlets or companies
  Other (please explain):
 
 
  Are there any important adjacencies within 250 feet of the property?
  Diplomat/Foreign agencies or offices
  Military or national security agencies or offices
  Other government agencies or offices
  High-profile institutions, groups or individuals
  Iconic buildings or other structures
  Media outlets or companies
  Other (please explain):
 
 
  CERTIFICATION STATEMENT
 
  Thank you for providing this information to the federal government as requested by the U.S. in its partnership with the real estate industry. Information submitted to the Department of Homeland Security in accordance with the procedures provided in the Critical Infrastructure Information Act of 2002 and its implementing regulations should be protected from public disclosure to the extent provided by the Act.

By signing below, you are certifying that this information is voluntarily provided for the purposes of the Critical Infrastructure Information Act of 2002; that this information is not required to be submitted to DHS or any other federal government department or agency pursuant to a legal requirement; that this information is not being submitted in lieu of independent compliance with a federal legal requirement; and that this information is not customarily in the public domain. You are providing this information in good faith, recognizing that any false representations may constitute a violation of 18 U.S.C. 1001 and are punishable by fine and imprisonment.

If DHS has questions about your incident report in the process of validating it, they will contact you by U.S. mail. You will have 30 days to respond to their questions to ensure the incident report remains open and active.

Once incident reports become validated by DHS, they are considered protected critical infrastructure information. If DHS determines that information you have submitted does not qualify for such protection, they will provide you with the opportunity to have the information destroyed.

Please print, sign and fax your completed incident report form to (703) 487-3570. You may also send the report form to DHS via controlled mail. Mailing instructions are on the Real Estate ISAC's website under "Report Incidents."



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