Data Breach Reporting Form

This form is to be completed by a church worker when a data breach occurs or is suspected to have occurred as soon as possible after a breach has occurred or is suspected. The first 24 hours may be critical to minimising harm to individuals whose data has been breached. Please call the Registrar on 5443 4711.

After completing this online form you will be emailed a copy - please keep this securely securely for future reference by the Churchwarden on church premises.

GENERAL INFORMATION

Parish *

Location/Address of breach (ie: where is the Office?) *

Full Name of Person who discovered the breach *

Email Address *

Mobile Number *

Name of any other witness/es to the data breach

DESCRIPTION OF DATA BREACH

How was the breach discovered *

If known, when did the breach occur

Type of personal information involved in the breach *

Are multiple records involved (estimate number) *

Are the records that have been breached: electronic or paper based *

If known, describe the cause and extent of the data breach

Is there any evidence of the data being misused by any unauthorised person

Is another organisation involved and if so, please provide details

DESCRIPTION OF ANY ACTION TAKEN TO REDUCE RISK

What action has already been taken to reduce the risk of harm to individuals? ie: recall of email sent to incorrect addressee, IT provider has been contacted to investigate hacking etc *

WHO HAS THE DATA BREACH BEEN DISCUSSED WITH SO FAR

Please provide details

IS FURTHER INVESTIGATION IN TO THE INCIDENT RECOMMENDED

Select One *

YesNo

Details *

REMEDIAL MEASURES TO DATE

If a breach of security measures was involved, what steps were taken to reduce further breaches from recurring?