Data Breach Incident Report

General Information

Date of Incident Reported By Contact Information Department

Incident Details

Date Discovered Description of the Incident Type of Data Breached Number of Records Affected Location of Breach

Detection & Response

How was the incident detected? Immediate Actions Taken Has the breach been contained? Yes No

Impact Assessment

Impact of the Breach Have affected parties been notified? Yes No

Follow-Up Actions

Future Prevention Measures Other Comments