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Report Data Breach
Louisiana Database Security Breach Reporting Form
Reporting Entity’s Information:
Name:
Phone:
Address:
City:
State:
Zip Code:
Submitter’s Information:
Name:
Company or Firm:
Email:
Phone:
Address:
City:
State:
Zip Code:
Details of the Breach:
Initial Breach Notice
Supplemental Breach Notice
Breach Details:
Approximate Number of Louisiana Residents Affected by the Breach (If known):
LA Residents:
Dates:
Date Breach Discovered:
Date Consumers Were Notified:
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:
Written Notification
Electronic Notification
Substitute Notification:
Upload a Cover Letter Here:
Uplaod a Breach Notification Sample here:
( Files must be under 1MB and one of the following types: .jpg, .png, .pdf )
Submit
