A Hand Tailored Suit Ltd
Data Breach Incident Form
Revision History
Version | Revision Date | Revised by | Section Revised |
1.01 | 22/05/18 | Company | Yes |
Document Control
Document Owner:
Company |
Document No:
1.6 |
Status:
Approved |
Date Approved:
22/05/18 |
Security Classification:
High |
Next Review Date:
22/08/18 |
Version:
V1.4 |
Department:
Data Retention & Protection |
1 Data Breach Incident Form (Template)
DPO/COMPLIANCE OFFICER/INVESTIGATOR DETAILS: | |||||||
NAME: | POSITION: | ||||||
DATE: | TIME: | ||||||
TEL: | EMAIL: | ||||||
INCIDENT INFORMATION: | |||||||
DATE/TIME OR PERIOD OF BREACH: | |||||||
DESCRIPTION & NATURE OF BREACH:
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TYPE OF BREACH: | |||||||
CATEGORIES OF DATA SUBJECTS AFFECTED: | |||||||
CATEGORIES OF PERSONAL DATA RECORDS CONCERNED: | |||||||
NO. OF DATA SUBJECTS AFFECTED: | NO. OF RECORDS INVOLVED: | ||||||
IMMEDIATE ACTION TAKEN TO CONTAIN/MITIGATE BREACH: | |||||||
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STAFF INVOLVED IN BREACH: | |||||||
PROCEDURES INVOLVED IN BREACH: | |||||||
THIRD PARTIES INVOLVED IN BREACH: | |||||||
BREACH NOTIFICATIONS: | |||||||
WAS THE SUPERVISORY AUTHORITY NOTIFIED? | YES/NO | ||||||
IF YES, WAS THIS WITHIN 72 HOURS? | YES/NO/NA | ||||||
If no to the above, provide reason(s) for delay
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WAS THE BELOW INFORMATION PROVIDED? (if applicable) | YES | NO | |||||
A description of the nature of the personal data breach | |||||||
The categories and approximate number of data subjects affected | |||||||
The categories and approximate number of personal data records concerned | |||||||
The name and contact details of the Data Protection Officer and/or any other relevant point of contact (for obtaining further information) | |||||||
A description of the likely consequences of the personal data breach | |||||||
A description of the measures taken or proposed to be taken to address the personal data breach (including measures to mitigate its possible adverse effects) | |||||||
WAS NOTIFICATION PROVIDED TO DATA SUBJECT? | YES/NO | ||||||
INVESTIGATION INFORMATION & OUTCOME ACTIONS: | |||||||
DETAILS OF INCIDENT INVESTIGATION: | |||||||
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PROCEDURE(S) REVISED DUE TO BREACH:
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STAFF TRAINING PROVIDED: (if applicable) | |||||||
DETAILS OF ACTIONS TAKEN AND INVESTIGATION OUTCOMES: | |||||||
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HAVE THE MITIGATING ACTIONS PRVENTED THE BREACH FROM OCCURRING AGAIN? (Describe) | |||||||
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WERE APPROPRIATE TECHNICAL MEASURES IN PLACE? | YES/NO | ||||||
If yes to the above, describe measures
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Investigator Signature: ____________________ Date: __________________
Investigator Name: ____________________ Authorised by: _________________ |
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