Data Breach Incident Report
1. Reporter Information
Full Name
Department/Role
Contact Information
Date of Report
2. Incident Details
Date & Time Discovered
Date & Time Occurred (if known)
Location/Systems Involved
Description of the Incident
3. Data Compromised
Type of Data Exposed
Estimated Number of Individuals Affected
Categories of Affected Individuals
4. Detection & Response
How Was the Breach Discovered?
Immediate Actions Taken
5. Impact Assessment
Potential Impact/Consequences
Other Organizations/Authorities Notified
6. Additional Information
Supporting Documents/Files
Other Comments