You must have JavaScript enabled to use this form.CONTACT AND BREACH DATES Report Date: Contact Information Name This field is required. Email Phone Address Address 2 City/Town State/Province - None -AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNova ScotiaOntarioPrince Edward IslandSaskatchewanNortrh West TerritoriesYukonNunavut ZIP/Postal Code Country - None -AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua & BarbudaArgentinaArmeniaArubaAscension IslandAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia & HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBritish Virgin IslandsBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCanary IslandsCape VerdeCaribbean NetherlandsCayman IslandsCentral African RepublicCeuta & MelillaChadChileChinaChristmas IslandClipperton IslandCocos (Keeling) IslandsColombiaComorosCongo - BrazzavilleCongo - KinshasaCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d’IvoireDenmarkDiego GarciaDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard & McDonald IslandsHondurasHong Kong SAR ChinaHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacao SAR ChinaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmar (Burma)NamibiaNauruNepalNetherlandsNetherlands AntillesNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorthern Mariana IslandsNorth KoreaNorth MacedoniaNorwayOmanOutlying OceaniaPakistanPalauPalestinian TerritoriesPanamaPapua New GuineaParaguayPeruPhilippinesPitcairn IslandsPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSamoaSan MarinoSarkSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia & South Sandwich IslandsSouth KoreaSouth SudanSpainSri LankaSt. BarthélemySt. HelenaSt. Kitts & NevisSt. LuciaSt. MartinSt. Pierre & MiquelonSt. Vincent & GrenadinesSudanSurinameSvalbard & Jan MayenSwedenSwitzerlandSyriaSão Tomé & PríncipeTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad & TobagoTristan da CunhaTunisiaTurkmenistanTurks & Caicos IslandsTuvaluTürkiyeU.S. Outlying IslandsU.S. Virgin IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamWallis & FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Date the breach occured Date the breach discovered Describe the breach (Provide sufficient detail, including cause):Was it a theft? Yes No Location of breach Estimate number of individuals directly affected by the privacy breach (i.e. Whose personal information has been compromised?): Type(s) of individuals affected (check all that apply): Client / Customer / Patient Employee Student Other: Click or tap here to enter text. Describe any immediate steps taken to reduce the harm of the breach (e.g. retrieval of breached information; replacement of locks; shut down of IT systems, etc.): PERSONAL INFORMATION INVOLVED Describe personal information involved (e.g. name, address, SIN#, medical history) Do not include or send us identifiable personal information: SAFEGUARDS Describe physical security measures (locks, alarm systems, etc.): Describe technical security measures (e.g. passwords, encryption, biometric security): Describe organizational security measures (e.g. security clearance, policies, training programs, contractual provisions): HARM FROM THE BREACHHARM FROM THE BREACH SELECTIONS Identify theft (most likely when the breach includes loss of S.I.N., credit card numbers, driver’s licence numbers, personal health numbers, debit card numbers with password information and any other information that can be used to commit financial fraud) Risk of physical harm (when the loss of information places any individual at risk of physical harm, stalking or harassment) Hurt, humiliation, damage to reputation or relationships (associated with the loss of information such as mental health records, medical records, and disciplinary records) Loss of business, employment, or professional opportunities (usually as a result of damage to reputation to an individual) Breach of contractual obligations (contractual provisions may require notification of third parties in the case of data loss or privacy breach) Financial loss or negative impact on credit record (associated with the loss of information) Damage to, or loss of, property (associated with the loss of information) Other (specify): MITIGATION AND PREVENTION Describe the immediate steps taken to contain and reduce the harm of breach (locks, changes, computer access codes changed and revoked, computer systems shut down, emails to wrongful recipients of information, etc.): INTERNAL NOTIFICATIONSWho did you notify when breach was identified?Have you notified the General Counsel? Yes No Have you notified Technology Services? Yes No Have you notified Campus Security? Yes No CAPTCHA
