Data breach notification

1. Contact Persons

Name

Function

Phone number

Email address

Processor contact person

Name

Jan van der Kleij

Function

Security Officer

Phone number

+31 (0)6-53838654

Email address

security@themedguidecompany.com

2. Is this a follow-up to a previous notification?

Yes No

If 'yes', what was the previous notification?

3. If 'yes' was answered to the previous question: what is the date of the original notification?

Date

4. If 'yes' was answered to question 2: what is the purpose of the follow-up notification?

Check the correct option.

A. Addition or amendment of information relating to the previous notification. B. Withdrawal of the previous notification.

5. When choosing option B for question 4: what is the reason for the withdrawal?

The reason for withdrawal is:

6. Provide a summary of the incident in which the personal data breach occurred.

7. How many individuals' personal data are involved in the breach?

A. Maximum

B. Minimum

8. Describe the group of people whose personal data are involved in the breach.

9. When did the breach occur?

Choose the correct option and enter the date(s).

A. On date

B. Between start date and end date of period

C. Not yet known

10. When was the breach discovered?

11. What is the nature of the breach?

Check the correct option(s). Note: multiple answers possible. A. Reading B. Copying C. Alterations D. Destruction E. Theft

12. Which types of personal data are involved?

Check the correct option(s). Note: multiple answers possible. A. Name, address, and place of residence details B. Phone numbers C. Email addresses or other addresses for electronic communication D. Access or identification data (e.g., username, password, or customer number) E. Health information F. Citizen Service Number (BSN)

G. Other, namely:

13. What consequences can the breach have for the privacy of the data subject?

Check the correct option(s). Note: multiple answers possible. A. Unauthorized parties may have gained knowledge of it B. Exposure to spam or phishing C. Fraud (identity fraud)

D. Other, namely:

14. What technical and organizational measures has your organization taken to address the breach and to prevent further breaches?

15. When was the data breach reported to the Client?

Date

Time

Client contact person

16. What means was used to make the report?

Check the correct option.

A. Telephone

B. Email

C. Form

D. Other, namely:

17. Have the personal data been encrypted, hashed, or otherwise made unintelligible or inaccessible to unauthorized parties?

Check the correct option.

A. Yes

B. No

C. Partially, namely:

18. If the personal data have been wholly or partially made unintelligible or inaccessible, in what way was this done?

Please also indicate the method of encryption.

19. In your opinion, is this report complete?

Check the correct option. A. Yes, the required information has been provided and no follow-up report is needed. B. No, a follow-up report with additional information about this breach will follow later.

20. Conclusion

Name of Processor signatory

Place

Date

21. The form was received by the Client on

Date

Time

By clicking 'Send', you agree to our Privacy Policy

Breach notification form

1. Contact Persons

Processor contact person

2. Is this a follow-up to a previous notification?

3. If 'yes' was answered to the previous question: what is the date of the original notification?

4. If 'yes' was answered to question 2: what is the purpose of the follow-up notification?

5. When choosing option B for question 4: what is the reason for the withdrawal?

6. Provide a summary of the incident in which the personal data breach occurred.

7. How many individuals' personal data are involved in the breach?

8. Describe the group of people whose personal data are involved in the breach.

9. When did the breach occur?

10. When was the breach discovered?

11. What is the nature of the breach?

12. Which types of personal data are involved?

13. What consequences can the breach have for the privacy of the data subject?

14. What technical and organizational measures has your organization taken to address the breach and to prevent further breaches?

15. When was the data breach reported to the Client?

16. What means was used to make the report?

17. Have the personal data been encrypted, hashed, or otherwise made unintelligible or inaccessible to unauthorized parties?

18. If the personal data have been wholly or partially made unintelligible or inaccessible, in what way was this done?

19. In your opinion, is this report complete?

20. Conclusion

21. The form was received by the Client on