Report Data Breach

Louisiana Database Security Breach Reporting Form

Reporting Entity’s Information:

Submitter’s Information:

Details of the Breach:
Approximate Number of Louisiana Residents Affected by the Breach (If known):


Information Involved in the Breach
(Please select all that apply:)
Social Security Numbers
Driver’s License / State ID Numbers
Financial Information (e.g. account, credit or debit card numbers)
Passport Numbers
Biometric Data
Other (specify):

Notification to Affected Individuals:
( Files must be under 1MB and one of the following types: .jpg, .png, .pdf )