Privacy Breach Report

A privacy breach occurs when there is unauthorized access to or collection, use, disclosure or disposal of personal information.

To report a privacy breach, complete and submit this online form. Fields marked with an asterisk (*) are mandatory, i.e. the form will not submit if they are left blank. Please note that you cannot save this form; you must complete it and submit it in a single session. Upon submitting the form, you will receive an email that includes all the data that you entered. The Information and Privacy Officer may contact you with follow-up questions upon receiving your report.

In your report, describe the types of personal information that have been breached, but do not include any information about identifiable individuals.

Your website

Contact information

丁香园AV Department

Contact name

Job title

Telephone

Email

Incident description

Date of breach

Date breach discovered

Date reported to 丁香园AV Information and Privacy Officer

Description of breach

Accessed or disclosed outside Canada? Yes No

Was the personal information accessed from or disclosed outside Canada?

Stored on server outside Canada? Yes No

Is the personal information being stored on a server or servers outside Canada? If yes, provide name of service provider and location of server(s) below

Service provider

Location of server Enter city and country

Individuals affected

Types of individuals affected 丁香园AV staff 丁香园AV faculty / instructors 丁香园AV students 丁香园AV alumni 丁香园AV retirees Other external third parties

Number of individuals whose privacy was breached

Number of individuals who inappropriately received information

Additional information relating to affected individuals

Personal Information breached

Additional information relating to personal information breached

Safeguards

Existing physical security measures Locked offices / desks / file cabinets Alarm systems Surveillance video Other

Select all that apply; elaborate below in "Additional information relating to safeguards"

Existing technical security measures Passwords Encryption Other

Select all that apply; elaborate below in "Additional information relating to safeguards"

Existing procedural security measures Security clearances Systems access protocols / restrictions Policies and procedures Training / education Contractual provisions Other

Select all that apply; elaborate below in "Additional information relating to safeguards"

Additional information relating to safeguards

Harm resulting from breach

Types of harm resulting from breach Identity theft Physical harm Hurt / humiliation / damage to reputation Loss of business / employment / educational opportunities Breach of contractual obligations Future breaches due to similar technical failures Failure to meet professional or certification standards Other

Select all that apply; elaborate below in "Additional information relating to harm"

Additional information relating to harm

Mitigation and prevention

Immediate steps taken to contain and reduce harm resulting from breach Information deleted or recovered Police notified Locks changed Security codes changed Passwords changed Systems access privileges revoked Information systems shut down Other

Select all that apply; elaborate below in "Additional information relating to mitigation and prevention"

Long-term strategies to correct the situation Staff training Revise / develop policy or procedures Privacy and security audit Change bulk email address Contractor supervision strategies Revise / develop contract language Other

Select all that apply; elaborate below in "Additional information relating to mitigation and prevention"

Additional information relating to mitigation and prevention

丁香园AV

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