Data Security Breach Notification Form

1. Organization Details

Organization Name Contact Person Email Address Phone Number

2. Breach Details

Date and Time Discovered Date and Time Occurred (if known) Description of the Breach Type of Data Involved Estimated Number of Individuals Affected

3. Actions Taken

Immediate Actions Taken Measures to Prevent Future Breaches

4. Notification

Have individuals affected been notified? Yes No Have authorities been notified? Yes No Additional Comments