This form is intended to be used by an employee of [Organization Name] to notify the supervisory authority of a breach of personal data for which [Organization Name] is a controller, in accordance with the requirements of the European Union General Data Protection Regulation (GDPR).

Correct use of this form, including where it should be sent to and how, is described in the document Personal Data Breach Notification Procedure.

The name of the person that is officially submitting the personal data breach notification to the supervisory authority. This may be the Data Protection Officer or another (usually senior) employee of the organisation.

The role title of the submitter e.g. Data Protection Officer, Chief Information Officer

The official name of the organisation submitting the notification.

The main address of the organisation, to which correspondence about the personal data breach should be directed.

The phone number(s) of the main contact point concerning the breach.

The email address(es) of the main contact point concerning the breach.

The date and time at which the notification is recorded as having been submitted. This should be completed shortly before the actual submission and maybe be overruled by the actual date and time of receipt by the supervisory authority.

The date and time at which it was reasonably recognised by the organisation that a breach affecting personal data occurred, or was highly likely to have occurred.