Privacy Breach Report Form

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Please describe the circumstances of the privacy breach, including:

  • What happened?
  • Describe how personal information came to be stolen or lost or used or disclosed without authority?
  • Date (or date range) of theft(s), loss(es) or unauthorized use(s) or disclosure(s) of personal information?
  • How was this privacy breach discovered?
  • Describe the nature of the personal information that was stolen or lost or used or disclosed without authority?
  • The number of individuals whose personal information may have been affected
  • Any other useful information
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