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1 Data Breach Incident Form (Template)

DPO/COMPLIANCE OFFICER/INVESTIGATOR DETAILS:
NAME:   POSITION:  
DATE:   TIME:  
TEL:   EMAIL:  
INCIDENT INFORMATION:
DATE/TIME OR PERIOD OF BREACH:
DESCRIPTION & NATURE OF BREACH:

 

 

 

 
TYPE OF BREACH:
CATEGORIES OF DATA SUBJECTS AFFECTED:
CATEGORIES OF PERSONAL DATA RECORDS CONCERNED:
NO. OF DATA SUBJECTS AFFECTED:   NO. OF RECORDS INVOLVED:
 
IMMEDIATE ACTION TAKEN TO CONTAIN/MITIGATE BREACH:
STAFF INVOLVED IN BREACH:
PROCEDURES INVOLVED IN BREACH:
THIRD PARTIES INVOLVED IN BREACH:
BREACH NOTIFICATIONS:
WAS THE SUPERVISORY AUTHORITY NOTIFIED? YES/NO
IF YES, WAS THIS WITHIN 72 HOURS? YES/NO/NA
If no to the above, provide reason(s) for delay

 

 

 

 
WAS THE BELOW INFORMATION PROVIDED? (if applicable) YES NO
A description of the nature of the personal data breach    
The categories and approximate number of data subjects affected    
The categories and approximate number of personal data records concerned    
The name and contact details of the Data Protection Officer and/or any other relevant point of contact (for obtaining further information)    
A description of the likely consequences of the personal data breach    
A description of the measures taken or proposed to be taken to address the personal data breach (including measures to mitigate its possible adverse effects)    
WAS NOTIFICATION PROVIDED TO DATA SUBJECT? YES/NO
INVESTIGATION INFORMATION & OUTCOME ACTIONS:
DETAILS OF INCIDENT INVESTIGATION:
PROCEDURE(S) REVISED DUE TO BREACH:

 

 
STAFF TRAINING PROVIDED: (if applicable)
DETAILS OF ACTIONS TAKEN AND INVESTIGATION OUTCOMES:
HAVE THE MITIGATING ACTIONS PRVENTED THE BREACH FROM OCCURRING AGAIN? (Describe)
WERE APPROPRIATE TECHNICAL MEASURES IN PLACE? YES/NO
If yes to the above, describe measures
 
Investigator Signature: ____________________                 Date: __________________

Investigator Name:       ____________________                Authorised by: _________________