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Breach Notification Form

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  • PRIVACY BREACH REPORTING FORM

    Right to Information and Protection of Privacy Act (RTIPPA) Personal Health Information Privacy and Access Act (PHIPAA)

    Use this form to report a privacy breach. A privacy breach occurs whenever there is unauthorized access, collection, use, disclosure or disposal of personal information and/or personal health information.

    WHEN YOU DISCOVER A PRIVACY BREACH:
    • Step 1: Contain the Breach
    • Step 2: Evaluate the Risks
    • Step 3: Notification
    • Step 4: Prevention

    The first three steps should be undertaken immediately upon discovery of the breach or in very quick succession. Regarding Step 3 and as per s.49(1)(c), you must notify the individual to whom the information relates and the Commissioner’s Office. The fourth step is undertaken once the causes of the breach are known, in an effort to find longer term solutions to the identified problem.
    STEPS INVOLVED:
    1. Complete this form.
    2. Submit the form online, or Send a completed .PDF version of the form by fax: 506.453.5963, email: access.info.privacy@gnb.ca or regular mail: 230-65 Regent Street, Fredericton, NB E3B 7H8
    3. If you have questions call: 506.453.5965 or 1.877.755.2811


    This form is adapted in part from material prepared by the Office of the Information and Privacy Commissioner for Nova Scotia, “Key Steps to Responding to Privacy Breaches” available online at:

    https://foipop.ns.ca/sites/default/files/publications/Key%20Steps%20-%20Full%20-%20Final%20-%202015Oct27_0_0.pdf

    and in part from material prepared by the Office of the Information and Privacy Commissioner for Newfoundland and Labrador, “Privacy Breach Reporting Form” available online at:

    http://www.oipc.nl.ca/pdfs/PrivacyBreachIncidentReportForm.pdf
  • CUSTODIAN/PUBLIC BODY INFORMATION

  • DESCRIPTION OF INCIDENT

  • Format of information involved:

  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY
  • CONTAINMENT OF BREACH

  • FORSEEABLE HARM

  • WHEN AND HOW TO NOTIFY

    When: Notification should occur as soon as possible following a breach. However, if you have contacted law enforcement authorities, you should determine from those authorities whether notification should be delayed in order not to impede a criminal investigation.

    How: The preferred method is direct-by phone, letter, email or in person. Indirect notification via website information, posted notices or media should generally only occur when direct notification could cause further harm, is prohibitive in cost, or contact information is lacking. Using multiple methods of notification in certain cases may be the most effective approach.
  • CORRECTIVE MEASURES

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