Data Breach Notification Report

1. Organization Details

Organization Name Contact Person Contact Email Contact Phone

2. Breach Details

Date/Time Discovered Description of the Breach Location of Breach

3. Personal Data Involved

Type of Data Affected Number of Data Subjects

4. Impact Assessment

Possible Consequences

5. Mitigation Measures

Details of Mitigation Measures Taken

6. Notification

Notified Supervisory Authority Date/Time of Notification Other Parties Notified (if any)

7. Additional Information