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Notification form of incident of personal data breaches

By filling out this form you notify ADAE of personal data breaches, as provided in the Commission Regulation (EU) No 611/2013 of 24 June 2013 on the measures applicable to the notification of personal data breaches under Directive 2002/58/EC of the European Parliament and of the Council on privacy and electronic communications..

Fill out the notification form...

Fields marked with * are mandatory.

Initial information on the personal data breach - Section 1

1. Name of the provider *


2. Identity and contact details of the data protection officer or other contact point where more information can be obtained.








3. Whether it concerns a first or second notification. *


4. Date and time of incident (if known; where necessary an estimate can be made), and of detection of incident




5. Circumstances of the personal data breach (e.g. loss, theft, copying) *



6. Nature and content of the personal data concerned *



7. Technical and organisational measures applied (or to be applied) by the provider to the affected personal data *



8. Relevant use of other providers (where applicable)


Further information on the personal data breach - Section 2


9. Summary of the incident that caused the personal data breach (including the physical location of the breach and the storage media involved):



10. Number of subscribers or individuals concerned:


11. Potential consequences and potential adverse effects on subscribers or individuals:



12. Technical and organisational measures taken by the provider to mitigate potential adverse effects:



Possible additional notification to subscribers or individuals


13. Content of notification:



14. Means of communication used:



15. Number of subscribers or individuals notified:


Possible cross-border issues

16. Personal data breach involving subscribers or individuals in other Member States:



17. Notification of other competent national authorities:





The requirement for this notification does not affect the obligations of providers as prescribed by Regulation 165/2011 of ADAE.

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