POPIA INCIDENT REPORT FORM

Alleged breach of security regarding personal information

Note: You can either use the downloadable form below or complete the online form below.

For the downloadable form, the incident must be reported to the Information Officer. It can be submitted by email to informationofficer@envisionafrica.co.za

A. DETAILS OF DATA SUBJECT / PERSON REPORTING

Name(s) and surname/ registered name of data subject / person reporting(Required)

First Last

Unique Identifier/ Identity Number:

Business Unit / Office

Residential, postal or business address:

Street Address City State / Province / Region ZIP / Postal Code Country

Contact number(s):

E-mail address / Fax No:(Required)

B. PARTICULARS OF BREACH / INCIDENT (Please provide detailed information regarding the incident)

Description of nature of breach, the personal information breached and where relevant data subject (particulars of individual whose information was breached)

Identity of person / entity that breached the information security (if known)

Particulars of witnesses / corroborating evidence (if available)

Consequences of breach (if known)

Proposal on immediate measures that should be taken

Recommendations on mitigation of adverse effects (if any)

Any other relevant information

CAPTCHA

POPIA INCIDENT REPORT FORM

Alleged breach of security regarding personal information

A. DETAILS OF DATA SUBJECT / PERSON REPORTING

B. PARTICULARS OF BREACH / INCIDENT (Please provide detailed information regarding the incident)

ADDRESS