Personal data breach notification form

Current General
Data Breach Information
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A. Type of notification

Please read the user guide on how to notify a Personal Data Breach before filling out this form.
Please also read the specific .

A.1 Type of notification

Comprehensive

In phases

Select 'comprehensive' when this is a complete notification.
Select 'in phases' when this is an initial, incomplete, notification, further information to follow (Art. 34(4) of the Regulation 2018/1725)

A.2 In phases

Initial

Follow-up

Conclusive

Follow-up: The is a follow-up to initial notification
Conclusive: This is the final information for the incident

Reference Case File

In case of a follow-up or conclusive type of notification, please indicate if available the Case File number provided by the ŷ�ޱ�Ͷע.

A.3 Registration number of data breach in your register

Yes

Art 34(6) of the Regulation 2018/1725

Reg. No

B. Data Controller EUI

B.1 Name of the organization (EUI)

B.2 Address

B.3 Contact person

B.4 Telephone

B.5 Email

B.6 Data protection officer

B.7 Telephone

B.8 Email

C. Data Processor

Indicate if the data breach was reported by the processor

Yes

C.1 Name of the organization

C.2 Address

C.3 Contact person

C.4 Telephone

C.5 Email

C.6 Data protection Officer

C.7 Telephone

C.8 Email