Privacy/Security Incident Reporting (PSIR) Form

The information reported in this form will be strictly confidential as permitted by law and will be used in part to determine whether a breach has occurred. Do not include specific protected health information (PHI) or personally identifiable information (PII) in this form.

 

Section 1 - Case Identifying Information

 
 
 
 
 
 
 
 
 
Phone
 
 
Phone
 
 
 
Phone
 
 

Section 2 - Summary of Privacy Incident

 

Do not include client identifying information (i.e., name, diagnosis). Tell us in your own words what happened.

 
 
 

Section 3 - Breakdown of Summary

 

Use the date that incident first occurred for recurring or multiple incidents.

 
mm/dd/yyyy
 

Use the date that incident ended for recurring or multiple incidents.

 
mm/dd/yyyy
 

Use the date any staff in your organization first became aware of the incident.

 
mm/dd/yyyy
 

AC Health includes the following departments: Behavioral Health, Environmental Health, Public Health, and Office of the Agency Director

 
mm/dd/yyyy
 
 
 
 
 
 
 
 
 

Section 4 - Data Elements Involved

 
 
 
 
 

Section 5 - Location of Disclosed Data

 
 

Section 6 – Safeguards/Mitigations/Actions Taken in Response to Event

 
 
 
 

Indicate whether the data has been returned, destroyed, or otherwise secured.

 

Please specify if attestation was written or verbal. If a written attestation is not attached, it will be considered to be verbal.

 
 
 

(Immediate actions taken to prevent further unauthorized disclosure of data)

 
 

Section 7 - Corrective Action Plan (CAP)

 

Please give an estimated date when you think the Corrective Action Plan (CAP) will be completed.

 
mm/dd/yyyy
 

A CAP is implemented in an attempt to prevent this type of privacy incident from reccurring in the future.

 
 
 

(Review & approval by DHCS is still required prior to dissemination of all notification letters)

 
 
 
 
 
 
Drop your files here
 

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