Privacy Breach Reporting Form for Members

Date of report:
MM slash DD slash YYYY
Contact information:
Contact person:
Industry Council Coordinator / Director
Industry council:
Phone
Email
Breach details (to be completed by person reporting the breach)
Date breach occurred:
MM slash DD slash YYYY
Date breach discovered:
MM slash DD slash YYYY
Describe the breach
(describe to the best of your knowledge what happened and how)
Number of individuals affected:
Type of individuals affected:
(Did the information compromised relate to members, employers, employees, or others)
Personal information involved:
(What sort of information was impacted by the breach, e.g., members address, members financial data, employee remuneration information, contact info etc)
Potential harm caused by breach (to be completed by Privacy Officer)

Contact information: