Security Incident Reporting

Data Breach Incident Reporting Form

Who is reporting the breach?

Department

Email address

Date breach was identified

Time breach was identified

Where the incident occurred

Severity of Incident

Low Medium High

Description of the Data Breach

Number of Data subjects affected by the incident

Type of data involved

Low risk data Medium risk data High risk data

What mitigations/ safeguards have been taken in response to the breach?

What steps are being taken to prevent this from happening again in future?