Regulatory Authority Breach Notification Form

Organisation Details Organisation Name Organisation Address Contact Person Email Phone Number Breach Details Date of Breach Date Discovered Summary of Breach Categories of Personal Data Affected Type of Breach Confidentiality Integrity Availability Number of Data Subjects Affected Number of Records Affected Actions Taken Measures Taken or Planned Have Data Subjects Been Notified? Yes No Not Required Have Other Authorities Been Notified? Yes No Additional Information