Vulnerability Disclosure Form


1. Reporter Information
Full Name *
Organisation / Affiliation (if applicable)*
Email Address*
Phone Number
Country*
Preferred Method of Communication*
Would you like to remain anonymous in public acknowledgements? *
2. Vulnerability Information
Title of the Vulnerability
Type of Vulnerability
Severity Level (if known)
Date Vulnerability Discovered
3. Affected System or Organisation
Name of Organisation or Service Affected
Sector
Affected Website / System / Application
URL or IP Address (if applicable)
Software / Product / Vendor (if known)
Version Number (if known)
4. Vulnerability Description
Detailed Description of the Vulnerability
Steps to Reproduce the Vulnerability
Impact of the Vulnerability
Potential Risk Level
5. Evidence and Supporting Information
Proof of Concept (PoC)
OR
Screenshots or Logs
References (if related to known vulnerabilities such as CVE)
6. Disclosure Status
Has this vulnerability been reported elsewhere? *
Has the organisation/vendor already been notified? *
Has the vulnerability been publicly disclosed? *
Do you agree to follow responsible disclosure guidelines? *
7. Declaration and Ethical Commitment
* I confirm that this vulnerability was discovered through lawful and ethical means and that I have not exploited the vulnerability for personal gain. I agree to follow the Coordinated Vulnerability Disclosure guidelines of CERT-MU.