Data Breach Incident Report Form
Reporter Details
Name
Email
Phone Number
Incident Details
Date Discovered
Time Discovered
Location/Department
Description of the Incident
Type of Data Involved
Number of Individuals Affected
Categories of Individuals Affected
Discovery & Containment
How was the data breach discovered?
Actions Taken Immediately
Is the breach contained?
Yes
No
Further Information
Parties Notified (e.g. authorities, management)
Additional Information