DataIncident | Inclusive care options

Date and time of incident: *

Date and time incident was discovered: *

Location of the incident: *

Department/service affected:

Reporter's Name: *

Reporter's Job role: *

Reporter Contact details (email & phone number): *

Type of data breach (e.g., loss, theft, unauthorized access, disclosure, system failure, cyberattack, etc.): *

Category of data affected (e.g., patient records, staff records, financial information, etc.):

Was personal data involved? (Yes/No): *

Yes
No

Number of individuals affected (approximate):

Detailed description of what happened *

How was the incident discovered? *

Who was involved? (e.g., staff, external party, unauthorized persons, etc.)

Any potential cause identified? (e.g., human error, system issue, hacking attempt, lost/stolen device, etc.):

Steps taken to contain the incident:

Who has been informed? (e.g., line manager, IT team, Data Protection Officer, NHS Digital): *

Any remedial action implemented? (e.g., password reset, revoked access, reported to police, etc.):

Potential harm to individuals or the organization:

Likelihood of data being misused: *

Reputational, financial, or operational risks identified:

Was the Information Commissioner’s Office (ICO) notified? *

Yes
No

Was NHS Digital/NHS England informed? *

Yes
No

Were affected individuals notified? *

Yes
No

Corrective measures planned (e.g., training, policy changes, system upgrades, disciplinary actions, etc.):

Supporting Evidence (if any):

Any Additional Information:

I confirm the above information to be accurate: *

Yes
No

Data Security Incident Reporting Form