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Tompkins County Health Insurance Consortium Breach Form
Use this form to report any possible breach of Consortium private or confidential information to the Tompkins County Information Security Compliance Officer.
Incident Information Section
section
Date of Incident
*
field type date
Nature of Breach
*
field type checkbox
Nature of Breach
Breach of Personally Identifiable Information
Security Breach
Other
Format of Information Breached
*
field type checkbox
Format of Information Breached
Hard Copy/Paper
Electronic/Computerized
Verbal
How was Information Breached?
*
field type checkbox
How was Information Breached?
Taken/Theft
Lost
Disclosed/Transferred
Accessed
Hacking/IT Incident
Other
Type of Violation
*
field type checkbox
Type of Violation
Physical
Administrative
Technical
Persons Affected
*
field type radio button
Persons Affected
Multiple Persons Identity Unknown
Specific Individuals listed below
Persons Affected Table
Last Name
field type single line
First Name
field type single line
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 Another Person
Number of People Affected
field type single line
Approximate if you don't know exactly.
Input blocked. Maximum character limit of 4000 characters reached.
Please describe the situation / incident
*
field type multi line
Input blocked. Maximum character limit of 4000 characters reached.
Submitter Information Section
section
Submitter's 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 Phone Number
*
field type single line
Input blocked. Maximum character limit of 4000 characters reached.
Submitter's Phone Number Extension
field type single line
Input blocked. Maximum character limit of 4000 characters reached.
Submitter's Email Address
*
field type email
Confirm Submitter's Email Address
*
field type email
Submitter's Agency
*
field type single line
Input blocked. Maximum character limit of 4000 characters reached.
Spam capture please leave empty