Data Breach Notification Form - Members

This notification form is for DXN members to report any suspected or actual unauthorized access, misuse, loss, disclosure, or other concerns relating to their personal data held or processed by DXN. The information required in this form must be completed and submitted within 24 hours of discovery.

All reports will be reviewed and assessed by DXN to determine whether the matter constitutes a personal data breach or privacy incident. Appropriate actions will be taken in accordance with the Personal Data Protection Act 2010 (PDPA), Personal Data Protection Department (PDPD) Guidelines on Data Breach Notification 2025, applicable data protection laws (including GDPR where relevant), and DXN policies.

All information submitted will be treated as strictly confidential and used only for the investigation and management of the reported data incident.

SECTION 1: MEMBER DETAILS
Field Information
Full Name (as per DXN records):
Member ID:
Email Address:
Contact Number:
Preferred Method of Contact:
Date / Time the Issue Was First Noticed:
How You Became Aware of the Issue:
Is this report made on your own behalf?
If No, please state your relationship to the affected member and provide authorisation (if applicable):
SECTION 2: DESCRIPTION OF INCIDENT / PRIVACY CONCERN
INSTRUCTION:

Describe the incident factually. Avoid assumptions about causes or breach classification. Attach supporting documents (screenshots, emails, reports, etc.) if available.

Field Information
Description of the Issue or Concern:
Date / Time You First Noticed the Issue:
Personal Data Potentially Involved:
Do you believe any sensitive personal data is involved?
If yes, please describe:
Were other individuals affected, to your knowledge?
If yes, please provide details (optional):
Country / Region of Personal Data Concerned:
Potential Impact or Harm You Are Aware of (e.g., unauthorised use of your data, identity misuse, financial loss, distress):
Supporting Documents (if any - attach here):
SECTION 3: ACTIONS TAKEN BY MEMBER (IF ANY)
INSTRUCTION:

Please indicate any actions you have personally taken after becoming aware of the issue. If none, you may leave this section blank.

Field Information
Actions Taken by You (if any - e.g. changed account password, contacted DXN Customer Service, stopped using affected account):
Date / Time Action Was Taken (if applicable):
Have you already contacted DXN regarding this issue?
If yes, please provide details (e.g. date, channel, reference number if available):
Are you still experiencing the issue?
Additional Information (if any):
SECTION 4: MEMBER CONSENT AND CONFIDENTIALITY NOTICE

By submitting this form, you acknowledge that the information provided will be processed by the DXN Group solely for the purposes of investigating, managing, and documenting the reported data incident, in accordance with the Personal Data Protection Act 2010 (PDPA), applicable data protection laws, and DXN policies.

All breach records and related documentation shall be retained for a minimum of 24 months from the date of closure, or longer where required by law or regulatory instruction. Access to this information is restricted to authorised personnel only and handled in accordance with confidentiality and security requirements.

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