This section is to be completed by the staff person who initially identified the privacy incident (e.g., received an email with confidential information, found forms in trash that should have been shredded, lost their documents, etc.) NO CONFIDENTIAL INFORMATION SHOULD BE INCLUDED IN THIS REPORT. Questions can be forwarded to: TBHIVSTD.Compliance@dshs.texas.gov.

For a copy of this report, please select "Send me a copy of my responses" at the bottom of the form.

Privacy Incidents should be reported to your Local Responsible Party (LRP) and/or Manager.

***Incidents should be reported to your respected leadership within your organization along with a copy of the submitted report. Reporting to leadership is the responsibility of the LRP and/or Manager. ***