Freedom of Information and Protection of Privacy: Privacy Incident Report Form
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If yes, what harm could result from the incident? Check one or more below.
Harm to individuals: Harm to the University of Guelph: Harm to public:
Risk to physical security Loss of trust in institution Risk to public health
Financial loss Damage to reputation Risk to public safety
Identity theft
Financial loss or
expenditure
Other
Damage to reputation or
relationships
Legal proceedings
Other Other
Part 4: Notification
(i) Notify University of Guelph Privacy Officer
Has the University’s Privacy Officer been notified of the incident? Yes No
Date of notification:
(ii) Notify authorities
Have the police or other authorities been notified of the incident (if necessary)? Yes No
Date of notification:
(iii) Notify Information Security
Has the Information Security Office been notified of the incident (if necessary)? Yes No
Date of notification:
(iv) Notify affected individuals
Have all affected individuals been notified of:
Description of the incident Yes No
The specifics of the information inappropriately accessed, collected, used or
disclosed
Yes No
Steps taken so far to address the incident Yes No
Future steps planned to prevent further privacy incidents Yes No
Additional information, if required, about how the individuals can protect
themselves
Yes No
Contact information for individual within the University to answer questions or
provide further information
Yes No
Date(s) of notification:
Form of notification: Email Telephone In person Other
Report completed by: Date: