Data Breach Notification Form
Last update : 24/03/2025
To inform the Client of a Data Breach, the Provider will use the following standard notification template:
|
Personal data breach incident report (included pseudonymized data) |
|
| Report Date | |
| Description of the data breach | |
| Incident date | |
| Incident duration | |
| Circumstances under which the incident was revealed |
|
| Date of incident discovery |
|
| Location of incident discovery |
|
| Date of client notification |
|
| Categories of Individuals Affected by the Incident |
|
| Approximate Number of Individuals Affected |
|
| Type of Personal Data Impacted by the Incident |
|
| Approximate Number of Personal Data Records Impacted by the Incident |
|
| Are the personal data anonymized? |
|
| Are the personal data pseudonymized? |
|
| Are the personal data encrypted? |
|
| Contact details of the Data Protection Officer (or the designated Client contact) for further information |
|
| IT Application(s) Affected by the Incident |
|
| Description of Possible Consequences of the Incident for the Individuals Affected |
|
| Description of Measures Taken or Planned by the Processor to Eliminate the Incident, as well as, if applicable, its Consequences |
|
| Contact details of the service provider involved in the post-mortem analysis (certified forensic expert) |
|
| Estimated Time to Eliminate All Consequences of the Incident |
|
| Other Essential Information Regarding the Incident |
|
If it is not possible to provide all information at once, the Provider commits to communicating them as they are identified.