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Breach Incident Investigation
Form
Submitter Information
section
Date
field type date
Date will be captured on form submission
Submitter's (YOU) Last Name
*
field type single line
Input blocked. Maximum character limit of 4000 characters reached.
Submitter's First Name
*
field type single line
Input blocked. Maximum character limit of 4000 characters reached.
Submitter's Email
field type email
An email confirmation will be sent to you when we receive this request. It will also be used for future communication if required.
Incident Information
section Expanded
Type of Information:
*
field type checkbox
Type of Information:
Personal/Private (PI)
Personal/Private Including (PHI)
Security Incident (SI)
(Personal info&SSN, DL#, NDID#, Acct#+PIN; PHI includes Health info.)
Form of Information:
*
field type checkbox
Form of Information:
Hard Copy/Paper
Electronic/Computerized
Verbal
Secured
Unsecured
What happened to PI/PHI?
*
field type checkbox
What happened to PI/PHI?
Taken/Theft
Destroyed
Lost
Disclosed
Accessed
Transferred
Hacking/IT Incident
Other - describe:
Type of Violation:
field type checkbox
Type of Safeguard Potentially Violated:
Type of Violation:
Physical
Administrative
Technical
Persons Affected
*
field type radio button
Persons Affected
Multiple Persons Identity Unknown
Specific Individuals listed below
Last Name
field type single line
First Name
field type single line
Row 1
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Last Name
field type single line
Input blocked. Maximum character limit of 4000 characters reached.
First Name
field type single line
Input blocked. Maximum character limit of 4000 characters reached.
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Add Another Person
Individuals Affected:
field type number
Approximate Number of Affected Individuals
NYS Residents Affected:
field type number
Total Number of Affected NYS Residents
Residents from Same Region:
field type number
Total Number of Residents from Same Region
Incident Start Date
*
field type date
Incident Start Time
field type single line
(If Known)
Input blocked. Maximum character limit of 4000 characters reached.
Incident End Date
field type date
Dept where Incident Occurred:
*
field type drop-down
Administration
Airport
Assessment
Assigned Counsel
Board of Elections
COFA
County Attorney
County Clerk
District Attorney
DSS
Emergency Response
Engineering
Environmental Health
Facilities
Finance
Health
Highway
ITS
Jail
Legislature
Medical Examiner
Mental Health
Personnel
Planning
Probation
Public Works
Purchasing
Sheriff
Solid Waste
TCAT
Tom Tran
WIC
Workforce
Youth Bureau
Youth Services
Person(s) who caused/created the incident
Last Name
field type single line
First Name
field type single line
Row 1
×
Last Name
field type single line
Input blocked. Maximum character limit of 4000 characters reached.
First Name
field type single line
Input blocked. Maximum character limit of 4000 characters reached.
×
Add
Person(s) who discovered the incident
Last Name
field type single line
First Name
field type single line
Date of Discovery
field type date
Row 1
×
Last Name
field type single line
Input blocked. Maximum character limit of 4000 characters reached.
First Name
field type single line
Input blocked. Maximum character limit of 4000 characters reached.
Date of Discovery
field type date
×
Add
Person(s) who reported the incident
Last Name
field type single line
First Name
field type single line
Date
field type date
Row 1
×
Last Name
field type single line
Input blocked. Maximum character limit of 4000 characters reached.
First Name
field type single line
Input blocked. Maximum character limit of 4000 characters reached.
Date
field type date
×
Add
Witness(es)
Last Name
field type single line
First Name
field type single line
Row 1
×
Last Name
field type single line
Input blocked. Maximum character limit of 4000 characters reached.
First Name
field type single line
Input blocked. Maximum character limit of 4000 characters reached.
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Add
General Description of the Breach
field type multi line
Please describe the incident and why you believe this to be a breach.
Once you submit this form, an investigator will be contacting you. If you have any supporting documentation, the investigator will review and upload at that time.
Input blocked. Maximum character limit of 4000 characters reached.
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