Personal Data Breach Report Form

Personal Information of Reporting Incident

Full Name

Department

Designation

Incident Information
Date of Incident
Reporting

Date Incident
was Discovered

Place of Incident
Incident Type
Confirmed Breach ☐ Suspected Breach ☐
# Incident Type

Loss or theft of confidential or sensitive data or equipment on

1
which such data is stored (e.g. loss of laptop, Flash Drive, External
☐
hard drives, iPad/tablet device, or paper record)

Equipment theft or failure (e.g. database, application sever

2
failures, software/system etc.) ☐

Unauthorized use of, access to or modification of data or

3
information systems ☐

Attempts (failed or successful) to gain unauthorized access to

4
information or IT system(s) ☐

5 Unauthorized disclosure of sensitive / confidential data

☐
6 Hacking attack
☐
7 Unforeseen circumstances such as a fire ,flood , earthquake etc.
☐
8 Other
☐
Security Incident Initial Assessment
1. Nature of ☐ Confidentiality Breach ☐ Integrity Breach
Breach
☐ Availability Breach
2. Approximat
e no. of
☐ 1~49 Is there a minor involve?
data
☐ 50~100
subjects or Y/N : _______
☐ 101 and above
records
involved

3. Data Description of Personal Data Involved

Possibly
involved ☐ Personal ☐ Sensitive ☐ Other Information
Information Personal
Information
 *pls. provide description

a. Description of Measures
Taken to Address the Breach

b. Actions taken to secure or

recover personal data
4. Remedial
Actions
Taken c. Actions performed or
proposed to mitigate possible
harm

d. Actions taken to inform the

data subjects
*state reason of delay if any

Employee’s Confirmation

I hereby declare that the details furnished above are true and correct to the best of my

knowledge and belief.
Full Name: Signature Date

Data Protection Officer Confirmation

Full Name: Signature Date

Karl Marxcuz R. Reyes