AI Incident Report Template
Article 73 of the EU AI Act requires providers of high-risk AI systems to report serious incidents to the national market surveillance authority on a 2 / 10 / 15 day clock. This template gives you the structure of the notification email so you can move fast when the clock is running.
Subject line
SERIOUS INCIDENT — Article 73 EU AI Act — [Provider Name] — [AI System Name] — [Date of Awareness]
Email body
Dear [Market Surveillance Authority],
We are reporting a serious incident affecting one of our high-risk AI systems under Article 73 of Regulation (EU) 2024/1689.
1. PROVIDER + AI SYSTEM IDENTIFICATION. Provider name + EU registration ID. AI system name + version. Article 6 / Annex III classification.
2. INCIDENT SUMMARY. When the incident occurred. When we became aware. Number of persons affected. Severity per Article 3(49): public-health threat / death-or-serious-harm / serious-FR-violation / critical-infrastructure-disruption.
3. WHAT HAPPENED. Plain-language description of the malfunction and its consequences.
4. CONTAINMENT. What we have done to prevent further harm: system taken offline / restricted use / fallback to manual / etc., with timestamps.
5. ROOT-CAUSE ANALYSIS. Initial findings, with caveat that full analysis ongoing.
6. CORRECTIVE MEASURES. What we will do: code fix, model retrain, oversight redesign. Timeline.
7. AFFECTED PERSONS. Has anyone been notified per GDPR Article 34 or sectoral law. Compensation plan if any.
8. CONTACT POINT. Name + email + phone of the incident commander for follow-up questions.
Yours sincerely,
[Provider compliance officer / DPO / equivalent]
If the AI is a medical device under MDR, file the same incident with the national medical-device competent authority under MDR Article 87 vigilance, same clock. If personal data was breached, file GDPR Article 33 separately within 72 hours.
Open the full incident response guide:
https://agenticfluxus.com/blog/ai-incident-response-guide
By John Ferguson · Founder, Agentic Fluxus · agenticfluxus.com · Amsterdam, Netherlands