Education Sector Data Breach Notification Form
1. Organization Information
Name of Organization
Contact Person
Position/Title
Contact Email
Contact Phone
2. Breach Details
Date Breach Discovered
Date Breach Occurred (if known)
Description of the Breach
3. Data Involved
Types of Personal Data Involved
Approximate Number of Individuals Affected
Categories of Data Subjects (students, staff, etc.)
4. Breach Impact & Response
Possible Consequences or Impact
Measures Taken or Proposed to Address the Breach
Reported to Authorities? (Yes/No, details if Yes)