[organization name] [confidentiality level]

DATA BREACH NOTIFICATION FORM TO THE SUPERVISORY AUTHORITY Commented [GDPR1]: This notification must be sent as soon
as possible, but within 72 hours from the date/time when the
suspected data breach has occurred.
** FREE PREVIEW VERSION **
Adapt this form to suit your correspondence style.

From: [Company Name] Commented [EUGDPR2]: Fill in with the complete name and
address of your company.

To: [name and address of the Supervisory authority]

Sent by:

 Post
 Email
 Fax
 Other ……. Commented [GDPR3]: Indicate through which channels you
have sent this notification.

1. …

2. Following the data breach, the following personal data were affected: [_______________]. Commented [EUGDPR4]: E.g. names, contact details,
accounts, etc.

3. …

4. We believe that the personal data breach might have the following consequences:
[list all possible consequences] Commented [EUGDPR5]: Please fill in with the …

5. …

6. …

** END OF FREE PREVIEW **

To download full version of this document click here:

https://advisera.com/eugdpracademy/documentation/data-breach-notification-form-to-the-
supervisory-authority/

Data Breach Notification Form to the Supervisory ver [version] from [date] Page 1 of 1
Authority

©2017 This template may be used by clients of Advisera Expert Solutions Ltd. in accordance with the License Agreement.