Report Data Breaches

This submission is required by Oregon Revised Statutes 646A.604.

Note: This form is only for use by businesses and state agencies, which are required to submit a sample notice if they experience a breach of personal information involving more than 250 Oregon consumers. If you are a consumer who wishes to file a complaint, please use our online complaint form.

Section 1 - Security Breach* = required

Sample of Consumer Notice

Select Sample of Consumer Notice file...
*
Files must be less than 100 MB
Allowed file types: pdf
Breached Organization Name*
Address
City
State
Zip Code
Date(s) of Breach (if known)
Start Date
End Date
Date(s) of Discovery of Breach
Date(s) Individual Notice Provided to Consumers
Was notification delayed because of a law enforcement investigation?
Type of Personal Information Involved in the Breach (select all that apply) (CTRL+click)
Brief Description of the Breach (1000 Character max)
Report Type
Number of Oregon Consumers Affected by the Breach
Approximate Number of Oregonians Affected by the Breach
Approximate Number of Individuals Affected by the Breach
Type of Breach
Was Substitute Notice Given (ORS 646.604(4)(d))?
Was Media Notice Given?
Section 2 - Information For Law Enforcement Purposes
The information provided in Section 2 is for Department of Justice use only.
Name of company contact or attorney whom the Attorney General may contact for further information?
Address Check if the address is the same as organization.
City
State
Zip Code
Telephone Number
Email Address
Was a law enforcement agency notified regarding the breach?
Law Enforcement Agency
Law Enforcement Contact
Law Enforcement Phone
Was a police report filed?
Police Report Number