Section 1

Identification of the provider

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

Initial information on the personal data breach (for completion in later notifications, where applicable)

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)

Section 2

Further information on the personal data breach

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