AITI - Report A Breach Form

Data Breach Notification

Initial Details

Are you a Data Controller or Data Processor

Data Controller

Data Processor

Organisation's Details

Organisation/Company Name

Company's correspondence address

Follow typical address format

Contact details of person reporting

Are you the organisation's Data Protection Officer?

Yes

Name of the person making this notification/report

Position

Email Address

Contact Number

Details of Incident

Are 250 or more people affected?

Yes

How many individuals were affected?

Date of incident

What type of Data is affected?

Individual's full name/alias

Identification Card number

Individual's date of birth

Individual's gender

Individual's account identifier and data for access into the account (without individual's name, alias, or ID number, password)

Individual's contact number

Individual's photograph

Individual's address

Individual's company

Health information

Financial information

Life/Health insurance information

Transaction information

Others

Please Specify

Cause/Suspected cause of incident

Location of affected database/server

Brunei

Overseas

Brunei and Overseas

Summary of the cause/suspected cause of incident and how your organisation first became aware of the breach

How was personal data affected?

Please specify

What are the potential risks of data breach to data subjects?

Threat to personal safety

Identity theft

Financial loss

Damage to reputation

Loss of business opportunities

No potential harm to data subjects

Others

Please state below

Any other affected organisations?

Please state below

Action taken by the organisation

Have the affected individuals been notified of the data breach incident?

Yes

No, but we intend to notify the affected individuals

No and we do not intend to notify the affected individuals

Please provide details

What action has your organisation taken?

Notify the individuals

Notify AITI within 3 days

Notify any other authorities

Issue a media statement regarding the breach of data

Others

Others, please specify

Please provide any supporting document relevant to the incident?

By submitting the information above, I confirm that I am authorised to make this notification on behalf of the organisation mentioned above, and confirm that the account as stated above is true and correct to the best of my knowledge and belief. I understand that the information provided by me in this notification will be used by AITI, the relevant sectoral regulator(s), and/or other government agencies for investigations and follow-up purposes in accordance with the relevant legislation(s) and/or regulation(s) that may be applicable. I further understand that AITI, the relevant sectoral regulator(s), and/or other government agencies may contact me to seek further information in relation to this notification.

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Authority for Info-communications Technology Industry of Brunei Darussalam

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