Organization Name Contact Number Email Address Other contact details Description of data breach Information involved in the data breach In addition, please select any categories that apply: Financial Data Identity Information TAX PIN Information Contact Information Home address, Telephone address, Email address Health Information Other Sensitive information Type of personal information involved in the data breach Provide detailed description of any action, including remedial action, you are taking, or intend to take to assist data subjects whose personal data was involved in the data breach Provide detailed description of any action you have taken, or are intending to take, to prevent reoccurrence Specify the steps your organisation/ agency recommends that individuals take to reduce the risk that they experience serious hard as a result of this data breach Other entities affected: (if the data breach described above was also a data breach of another organisation, provide their identity and contact details) Date the breach occurred: (provide your best estimate if the exact date is not known) Was data breach was reported after 72 hours of discovery? Date the breach was discovered (provide your best estimate if the exact date is not known) If YES, please specify why Primary cause of breach Malicious or criminal attack System Fault Human Error Other If other, please specify. Description of how the data breach occurred Number of data subjects whose personal data is involved in the data breach 1-10 11-100 101-1,000 1,001-10,000 10,001-100,000 100,001-1,000,000 Exact number of data subjects whose personal data is involved in the breach (please provide your best estimate) Is there any other information you wish to provide at this stage, or any matters that you wish to draw to the ODPC’S attention? List of any other data protection authorities, law enforcement bodies or regulatory bodies that you have reported, or intend to report, this data breach to If you wish to provide further information or additional documents after you submit the form, you may email them to email@example.com Request for Confidentiality If you request any information in this form be held by the ODPC in confidence, please provide further information to support the request
The ODPC will respect the confidence of commercially or operationally sensitive information provided voluntarily in support of a data breach notification, and will only disclose this information after consulting with you, and with your agreement or where required by law.
I hereby declare that the information given in this application is true and correct to the best of my knowledge and belief
Review and Submit
Please review the information that you have provided about the data breach. If you would like to change anything, you can return to the relevant section . Once you are ready to submit your form, click the Submit button below. You can have a copy sent to an email address of your choice.