Form CVDP - Personal Data Breach Reporting Form

Data Processor:

Dual Borgstena Textile Czech Republic s.r.o., with registered office at Otín 3, Areál Jitka a.s., 37701, Jindrichuv Hradec, CZECH REPUBLIC, taxpayer no. CZ01507206.

Legal Basis for Exercising the Right:

Articles 33 and 34 of the General Data Protection Regulation - Regulation (EU) 2016/679 of the European Parliament and of the Council of April 27, 2016.

Incident reporting:

The protection and security of personal data processed at Dual Borgstena Textile Czech Republic is a priority for this organization.

To this end, and in order to be able to react quickly and effectively to any occurrence indicating a possible violation of personal data, we have implemented an internal incident management system for personal data, and this form is an important tool for communication/information from the outside.

The Data Protection Officer of Dual Borgstena Textile Czech Republic is internally responsible for the personal data incident management process.

In these terms, we ask and thank you that if you detect, become aware of, or have indications, by any means, of the practice of any facts or of any anomalous occurrence, which has or may have a negative impact on the security of personal data processed by Dual Borgstena Textile Czech Republic, you inform us immediately by completing this form.

Once completed, this form should be addressed to the Data Protection Officer of Dual Borgstena Textile Czech Republic, using one of the following communication channels:

a) e-mail: dataprotection@borgstena.com (if you choose this contact method, please write "CVDP Form" in the "Subject" field).

b) by post: Otín 3, Areál Jitka a.s., 37701, Jindrichuv Hradec, CZECH REPUBLIC (if you choose this method of contact, you must send this form by registered mail, so that the date of receipt can be verified).

c) delivery in person: Otín 3, Areál Jitka a.s., 37701, Jindrichuv Hradec, CZECH REPUBLIC (if you choose this method of contact, please be accompanied by an identification document).

Description of the anomalous/suspicious facts*

Describe the anomalous/suspected facts as fully as possible, by indicating/characterizing the types of personal data affected, the categories of data subjects affected, the damage recorded and the person/s responsible (or suspected) for the facts described. Every detail can be important.

Indicate when you became aware of the anomalous/suspicious facts described:

Date

Indicate the date of the facts.

Time

Indicate the time of the facts.

If you do not know when the anomalous/suspicious events previously described occurred, indicate:

Don't know.

Awareness of anomalous/suspicious facts*

Describe as fully as possible all the circumstances relating to your knowledge of the facts described above. Every detail can be important.

Indicate when you became aware of the anomalous/suspicious facts described above:

Date*

Indicate when you became aware of the facts.

Time

Indicate when you became aware of the facts.

Other information/observations

Thank you for the information you have provided through this form, which will be treated by the Data Protection Officer of Dual Borgstena Textile Czech Republic with the utmost attention and speed.

If you have any questions regarding this form, please let us know your preferred means of contact.

The Data Protection Officer, within the limits of the law, will keep your identity confidential, and data processing will be carried out exclusively for the purposes of managing data breach incidents, under the terms of the Data Protection Policy accessible at www.borgstena.com and will respond to any request to exercise data protection rights received through any of the communication channels.

The Participant (optional)

Name

Time

.

Citizen card

Valid until

Landline

Cell Phone

Email

example@example.com