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SECURITY INFORMATION & DATA BREACH ESCALATION FORM

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Security Information & Data Breach Escalation Form

Date of request*

TYPE OF INCIDENT

The information discolsed herein is collected with the sole purpose of identifying the incident, generating respective action plans and to facilitate the investigation of the respective incident

This form intends to esclate a potential issue related to Information Security
Information Security Officier (ISO)

This form intends to esclate a potential issue related to Data Protection
Data Protection (DPO)

DETAILS OF THE PERSON ESCALATING THE INCIDENT

Insert full name*

Insert position*

Insert e-mail address*

Acting in representation of another person

DETAILS OF THE INCIDENT

Insert description of the incident*

Select date of occurance of the incident*

Insert number of data subject affected (if known)

Insert type of data impacted*

Insert details on data impacted*

Insert when have you became aware of the incident*

Insert how have you become aware of the incident

Insert summary of the incident*

Please include as much details as possible to better understand what happened

Please detail wheter the Personal Data is not accessible or partially accessible (Availability), incomplete or inaccurate (Integrity) and/or if the data came to knoledge of an authorised person or was delivered to a different person tha the intended recipient (Confidentiality).

Availability

Integrity

Confidentiality

Insert reason

Insert further comments, foreseen impacts and/or recommendations*

I do agree to use my personal data

I want to receive a copy e-mail