Data breach form

Contact data

Which organisation is affected?

Which application is affected?

Details of Data breach

Hacking

Theft

Incorrect shipment

Software Bug

Loss of data, Skimming

Loss of passwords

False disposal

Malware

Other

Data breach categories

Are you personaly affected in the incident

Yes

No

Date/Time of the incident

Compromised Application/Software/Data Base

Affected persons/individuals

Approximate number of persons affected

Approximate number of persons records

Details of incident/Description of the breach

Have concerned person already been notified?

Yes

No

Don't know

Are we allowed to disclose your identity to the organization

Yes

No

Have you already informed the police or other Authorities

Yes

No

Terms and conditions this is a link

Place for content/media (image, video)