📝 AI System Impact Assessment (AIIA) — Template

System/Model Name:
Owner:
Use Case/Purpose:
Users/Affected Parties:
Decision Impact Level: High / Medium / Low

1. Data

• Sources, rights/consent, retention, security controls

2. Risks & Mitigations

| Risk | Likelihood | Impact | Mitigation | Owner | |—|—|—|—|—| | Bias in outcomes | Medium | High | Balanced dataset; bias testing pre‑release | AI Ethics Officer |

3. Human Oversight

Describe review points, escalation path, and final decision authority.

4. Privacy & Security

PII handling, encryption, access controls, incident response alignment.

5. Approvals

• ISSM: __ Date: __
• AI Ethics Officer: __ Date: __
• System Owner: __ Date: __