Personal Data Breach Incident Response Procedure

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Last modified: January 14th, 2022
This page is regularly updated to reflect continued monitoring, accuracy and comprehensiveness.

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Background

A personal data breach is any incident of security, lack of controls, system or human failure, error or issue that leads to, or results in, the destruction, loss, alteration, unauthorized disclosure of, or access to, personal data.

Vendasta is committed to the obligations in accordance with the GDPR. We are progressing towards our goal to maintain a robust and structured program for compliance adherence and monitoring to ensure that the correct procedures, controls and measures are in place where necessary. However, breaches can still occur, so this procedure states our intent and objectives for dealing with such data breaches involving personal information.

Objectives

  • To adhere to the GDPR and other Data Protection laws and to have robust and adequate procedures and controls in place for identifying, investigating, reporting and recording any data breaches
  • To develop and implement adequate, effective and appropriate technical and organisational measures to ensure a high level of security with regards to personal information
  • To have adequate and effective risk management procedures for assessing any risks presented by processing personal information
  • To ensure that any data breaches are reported to the correct regulatory bodies within the timeframes.
  • To use breach investigations and logs to assess the root cause of any breaches and to implement a full review to prevent further incidents from occurring
  • To use the Personal Data Breach Incident Form for all personal data breaches, regardless of severity so that any patterns in causes can be identified and corrected
  • To protect all on board on Vendasta platform – including their data, information and identity
  • To ensure that the Supervisory Authority is notified of the data breach (where applicable) with immediate effect and at the latest, within 72 hours after having become aware of the breach

Key Concepts

Personal Information

Personal information means information or an opinion about an identified individual or an individual who is reasonably identifiable, whether the information is true or not, and whether the information is recorded in a material form or not. It includes all personal information regardless of its source and regardless of whether it is publicly available

Data Breach

A personal data breach occurs when personal information is subjected to unauthorized access or disclosure, or where the information is lost and unauthorized access or disclosure is likely to occur.

e.g Data breaches resulting from human error

  • Loss of employee’s laptop, USB or paper records that contain personal information (e.g. left on a train, at the airport, stolen from the car etc.)
  • Employee accidentally disclosing personal information to the wrong recipient or exposing any resource containing personal information to wrong recipients or to the public, sending correspondence with personal or sensitive information to the wrong person etc

e.g Data breaches resulting from malicious activity

  • Hacking into employee’s email accounts, softwares, applications or datasets etc containing Personal Information
  • Scams that trick employees into releasing personal information
  • Inappropriate or fraudulent use of datasets containing personal information

e.g Data breaches resulting from unforeseen circumstances

  • Unforeseen events that occur to Vendasta or to any Third party who holds personal information on behalf of Vendasta or if a cloud service provider suffers a data breach

 

Eligible Data Breach

An eligible data breach is a data breach that is likely to result in serious harm to any of the individuals to whom the information relates, in which case Vendasta must inform either the data controller or the Supervisory Authority and affected data subject(s) depending on Vendasta’s role.

 

Key Roles and Responsibilities

Role

Responsibilities

Vendasta Employee
  • Report incidents immediately to their Manager 
  • Complete the Data Breach Report and give to Manager
  • Participate in investigations as required
Manager (head of the relevant function)
  • Receive Data Breach Reports from Vendasta employees within their area
  • Contain breach, remediate harm, and preserve evidence
  • Forward Data Breach Report to the Data Privacy/Protection Officer
  • Assist with investigations as required
Data Privacy/Protection Officer
  • Receive Data Breach Reports from Manager and alerts CTO of potential data breach
  • Conduct a preliminary investigation
  • Provide findings to CTO and alerts legal personnel
  • Participate as a member of the Data Breach Response Group
  • Record incidents and proceedings in the Non-Compliance Register 
Chief Technology Officer CTO
  • Receive preliminary investigation findings from Data Privacy/Protection Officer
  • Determine the seriousness of the data breach
  • Decide whether to convene of the Data Breach Response Team and whether to include additional Members
  • Approve assessment by Data Breach Response Team
  • Make notifications as appropriate
  • Conduct post-action review
Data Breach Response Team
  • Assess preliminary investigation
  • Assess containment and/or remediation actions
  • Assess whether an eligible data breach has occurred
  • Assess notification requirements
  • Assist with post-action review

 

Timeframes

An actual or suspected data breach must be investigated and managed as soon as any Vendasta employee becomes aware of the data breach, or suspects that it has occurred.

 

Suspected and Eligible Data Breach

Eligible Data Breach

Assessment must be reasonable and expeditious

All reasonable steps to complete the assessment within 30 days of the date that Vendasta became aware of an eligible or suspected data breach.

This timeframe should be treated as the maximum timeframe for completing the assessment

Vendasta as Data Controller: 

Notify the Supervisory Authority and affected data subject(s) as soon as practicable after becoming aware of an eligible data breach

The Supervisory Authority is notified of the breach no later than 72 hours and is kept notified throughout any breach investigation, being provided with a full report, including outcomes and mitigating actions as soon as possible, and always within any specified timeframes.

If for any reason it is not possible to notify the Supervisory Authority of the breach within 72 hours, the notification will be made as soon as is feasible, accompanied by reasons for any delay.

Vendasta as Data Processor:

The processor shall notify the controller without undue delay after becoming aware of a personal data breach.

Personal Data Breach Incident Response Procedure

 

1 – Report and contain

Personal Data Breach Reporting

If any Vendasta employee becomes aware of an actual or suspected data breach, they must report it as soon as possible. Reporting incidents in full and with immediate effect is essential so that breach procedures can be initiated and followed without delay.

These procedures are for the protection of Vendasta, its employees, partners, vendors, customers and third parties and are very important for legal regulatory compliance.

They should immediately :

  1. Record the details of data breach
  2. Provide a copy of this Data Breach Report to direct Manager
  3. Keep it confidential except where it is necessary to disclose information about the incident
Containing Data Breaches and Remediating Harm

As soon as a breach is reported, the Manager is responsible for taking immediate action to contain the breach and remediate harm, including by seeking assistance from the appropriate business functions or third parties as necessary.

At any time, appropriate steps should be taken to reduce any potential harm to affected data subjects.

Remedial actions are not in the scope of this document due to the vast nature of breaches and the variety of actions that can be taken; however, the aim of any such actions should be to stop any further risk/breach. The actions taken are noted on the incident record in all cases.

Preserving Evidence of a Suspected Data Breach

The Manager must take any reasonable steps available to them to preserve and/or record evidence of an actual or suspected data breach and provide this Data Breach Report with remedial action details to the Privacy/Protection Officer.

 

2 – Investigate

Preliminary Investigation

The Data Privacy/Protection Officer must review this report of an actual or suspected data breach as soon as reasonably practicable.

Data Privacy/Protection Officer must:

  1. notify the CTO that a data breach report has been received
  2. assess what containment and/or remediation actions have already been taken by manager (if any) and whether any further actions are required and
  3. undertake any preliminary investigations necessary to confirm the report and/or seek any clarification or additional details
Initial assessment

Once the report has been reviewed and preliminary investigation is done to confirm the incident, the Data Privacy/Protection Officer must make an initial assessment of:

  1. whether the reported incident is a data breach or not (such that a further investigation is required or not)
  2. If there is a data breach, give an initial risk rating to all relevant areas of impact including:
    1. number of data subjects affected by the breach or suspected breach;
    2. type of personal information;
    3. likelihood of serious harm to affected data subjects
    4. Incident indicates a problem in Vendasta’s processes, systems, products or services;
    5. Whether remedial actions have successfully prevented harm to affected data subjects
Reporting

The Data Privacy/Protection Officer must provide the findings of the preliminary investigation to the CTO as soon as possible.

 

3 – Assessment

Escalation to Data Breach Response Team

The CTO will assess the preliminary investigation findings to determine whether to convene the Data Breach Response Team. The CTO may request further information if required, to make this determination.

If the CTO:

  1. determines the incident is not a data breach, it will not be escalated to the Data Breach Response Team and The CTO will direct Manager and Data Privacy/Protection Officer to take any action reasonably necessary to close-out the incident appropriately;
  2. determines the incident is a data breach and serious harm is possible, it should be escalated to the Data Breach Response Team for further assessment
  3. determines the incident is a data breach and serious harm is at most unlikely, it should not be escalated to the Data Breach Response Team. The CTO will direct the Manager and Data Privacy/Protection Officer to take any action reasonably necessary to close-out the incident appropriately and record the incident in the Risk Register. It is for the CTO to decide if voluntary notification to affected data subjects and/or Supervisory Authority is required or not.
Data Breach Response Team

The Data Breach Response Team comprises the following permanent members:

CTO (or nominee)

Data Privacy/Compliance (or nominee)

Risk (or nominee)

IT Security and Architecture (or nominee)

CTO may co-opt additional members onto the Data Breach Response Team or engage external providers to assist in containment or investigation of the breach, depending on the nature or severity of the data breach like:

PeopleOps  Where data breach involves employees (as affected individuals or involved in the breach)

Micro Services Where data breach involves security gap in application

Data Where data breach involves unauthorized access to data sets

Partners Where data breach involves a Partner

Third parties Where data breach involves third parties like sub-processors or service providers

Services like legal for specialist legal advice, accounting or auditing if breach involves financial  information, public relations to handle media to manage reputational damages etc.

Data Breach Assessment

If the incident is escalated to the Data Breach Response team then the Data Breach Response Team must have a secure meeting as soon as possible to discuss the Data Breach Report and the results of the preliminary investigation (including any containment and/or remediation steps taken).

The Data Breach Response Team is responsible for assessing and determining whether:

  1. the data breach is likely to result in serious harm to the affected data subject(s)
  2. mandatory notification to Supervisory Authority and affected data subject(s) is required or
  3. if notification is not mandatory, voluntary notification to Supervisory Authority and affected data subject(s) is desirable

In conducting the assessment, the following issues must be addressed:

  1. the type of personal information involved;
  2. the context of the affected information and the breach;
  3. the cause and extent of the breach; and
  4. the risk of serious harm to affected data subject(s).

The CTO will be responsible for determining whether an eligible data breach has occurred, based on the Data Breach Response Group’s assessment and recommendation.

The Data Breach Response Team must complete the Eligible Data Breach Assessment Form in all cases, the assessment should be conducted and completed within 30 days of the date that the data breach occurred.

Record Keeping and Evidence Preservation

Data Breach Response team must keep records of all steps taken in response to the data breach and decisions made in connection with it. This includes:

  1. keeping a record of all steps taken during the preliminary investigation and subsequent assessment of the reported data breach; and
  2. ensuring that any relevant evidence of the data breach (such as snapshots, forensic or other investigative processes) is preserved and stored securely.

The information may be required by the investigators, legal advisors, law enforcement and regulators, as well as for use in preparing notifications to and communications with affected individuals and the Supervisory Authority and any other regulator or relevant entities.

Evidence and records must be sufficient to demonstrate to the Supervisory Authority the reasonable steps taken to comply with statutory and other legal obligations.

Where the assessment by the Data Breach Response Team requires legal advice:

  1. All documents, communications, reports and notes must be marked ‘Confidential’ and
  2. no other reports, forms or other documents relating to the data breach should be prepared except those required.

 

4 – Notification

Non-eligible Data Breaches

If the CTO determines the data breach is not an eligible data breach, the Data Privacy/Protection Officer will record the incident in the risk register and undertake action that is reasonably necessary to close-out the incident appropriately along with the Area Manager.

The close-out actions may include giving voluntary notification to the data controllers, if Vendasta is data processor or to Supervisory Authority and affected data subject(s), if Vendasta is data controller.

Eligible Data Breaches
Vendasta as Data Processor:

If an eligible breach has occurred exposing personal information which was collected by a data controller and then Vendasta being in the role of data processor only, should notify the controller without undue delay after becoming aware of a personal data breach.

It is the data controller’s responsibility to notify the Supervisory Authority and affected data subject(s) (Article 33 GDPR). Also, It is equally important to review the Data Protection Agreement between controller and processor (Vendasta) to check for any contractual obligations agreed in the event of a personal data breach and its notifications (Article 28 GDPR).

Vendasta as Data Controller:

If an eligible breach has occurred exposing personal information which was collected and processed by Vendasta, then It is mandatory for Vendasta to notify the Supervisory Authority (Information Commissioner) and affected data subject(s) as soon as practicable after becoming aware of an eligible data breach.

The Supervisory Authority is notified of the breach no later than 72 hours and is kept notified throughout any breach investigation, being provided with a full report, including outcomes and mitigating actions as soon as possible, and always within any specified timeframes. The 30 day assessment timeframe is the maximum timeframe for completing the risk assessment. If for any reason it is not possible to notify the Supervisory Authority of the breach within 72 hours, the notification will be made as soon as is feasible, accompanied by reasons for any delay.

At any time, steps should be taken to reduce any potential harm to affected data subject(s). If remedial action is successful in preventing serious harm to affected data subject(s), notification may not be mandatory.

Notification to Supervisory Authority

Online notification submission is preferred by most of the regulatory authorities worldwide.

It is mandatory to include the following information in the notification:

  1. the identity and contact details of the data controller (Vendasta);
  2. a description of the eligible data breach;
  3. kind(s) of Personal Information affected by the breach;
  4. categories of the data subjects affected; and
  5. recommended steps that data subject(s) should take to protect their position in response to the data breach.

It is optional to include the following additional information in the initial report like:

  1. details about the circumstances of the breach;
  2. number of data subject(s) affected;
  3. additional information about the steps taken to respond to the breach; and
  4. any other information that might be relevant to assist Supervisory Authority in considering the appropriate response to the notification.

Notification to the Supervisory Authority must be approved and signed by the CTO prior to being sent. Once the notification is submitted, the Supervisory Authority’s acknowledgement of receipt of the eligible data breach statement and reference number must be recorded.

Notification to affected Data Subject(s)

The Data Breach Response Team is responsible for preparing a draft notification and assessing the options available for notifying affected data subject(s) of the data breach.

The notification to affected data subject(s) must include:

  1. how and when a data breach happened;
  2. the types of the Personal Information involved in the data breach;
  3. what steps have been taken and what will be taken to reduce or eliminate the risk of harm brought about by the data breach;
  4. any assurances (if applicable) about what data has not been disclosed (i.e. if a breach only affects an individual’s basic identity or contact information, but not their financial information or any sensitive information);
  5. what steps the data subject(s) can take to protect themselves and what Vendasta will do to assist them to do this (if applicable);
  6. contact details of Vendasta for questions or requests for information or assistance (e.g. helpline numbers, e-mail addresses or websites);
  7. whether Supervisory Authority has been notified about the data breach; and
  8. how a data subject can lodge a privacy complaint with the Supervisory Authority.

Notification to the affected data subject(s) must be approved and signed by the CTO prior to being sent out to relevant persons and the CTO (or appropriate business unit) is responsible for sending notifications to affected data subject(s).

CTO must keep record of:

  1. the date, time and method of notification to each data subject; and
  2. any confirmation of receipt of the notification received from a data subject (unless the data breach involves a very large number of individuals, and it would be impractical to do so).

Important: It is important to identify data subjects who are affected by the breach rather than to move fast by sending notifications to all including those who are/may not be affected.

Additional Notifications

There may also be other notifications which would be appropriate in the particular circumstances (e.g. notifying insurers, the police, cybercrime agencies etc.) If the Data Breach Response Team determines that additional notification is desirable, approval must be obtained from the CTO before such notification is made.

Additional Considerations

If law enforcement authorities are involved, check with them whether notification should be withheld or delayed to avoid compromising the investigation; and

If the data breach is likely to attract publicity, the public relations office must be briefed to prepare media content. All media or public enquiries must be referred to Director, Media and Corporate Relations and responses should be approved by the CTO prior to release.

 

5 – Review

Post Breach Review

The CTO is responsible for conducting a post-breach review and assessment, once the immediate consequences of the data breach have been dealt with.

In conducting the review, the CTO:

  1. should seek informal input and assistance from other members of the Data Breach Response Team and other business units, as required;
  2. must
    1. complete any further investigations as necessary or desirable;
    2. determine whether any data handling or data security practices led or contributed to the relevant data breach;
    3. consider whether there are any further actions that need to be taken as a result of the relevant data breach, such as:
      1. updating security measures;
      2. reviewing and updating this data breach response plan;
      3. making appropriate changes to practices, systems, services, other processes, policies and procedures;
      4. revising training practices;
      5. reviewing partner, vendor or third party’s security/contract terms and ongoing engagement; and
      6. considering undertaking an audit to ensure necessary outcomes are implemented.

Update Risk Register/Non-Compliance Register as appropriate, provide a written report for audit, compliance and risk with findings and recommendations for the further actions.

Below are some examples of further actions:

If the data breach was caused by employee conduct, provide training, additional supervision, auditing and monitoring, update procedures or policies, introduce new controls or restrictions etc to prevent data breach from reoccurring.

If the data breach was caused by a security breach, improve IT security, improve building security and increase security surveillance, apply any additional security protections to protect the Personal Information (e.g. encryption, use of pseudonyms), introduce any new access restrictions

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