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Privacy Breach Reporting Form

If you intend to seek advice from Manitoba Ombudsman about how to respond to a privacy breach and determine what actions should be taken, you should report this incident as soon as possible even when all of the information is not yet known.

Please note that this reporting form is to be used only by public bodies and trustees for the purposes of reporting a privacy breach to Manitoba Ombudsman. Individuals who believe that their personal or personal health information has been collected, used or disclosed by a public body or trustee in a way that does not comply with FIPPA or PHIA may make a complaint to the ombudsman – please contact us for more information or follow these links:

When completing this form, please provide as much information as possible. Please do not include identifiable personal or personal health information. If a question does not apply to your situation, or you do not know the answer to something, please indicate this on the form.  If you have any questions about completing the form, contact us at (204) 982-9130 or toll free 1-800-665-0531.

You will be contacted by our office after we receive the form. 

Reporting a privacy breach does not preclude Manitoba Ombudsman from conducting an investigation. A privacy breach report will help our office determine the type of response required, such as an informal discussion or the initiation of an investigation.

CONTACT INFORMATION

* indicates required field

CONTACT PERSON

* indicates required field

REASON FOR REPORTING

* indicates required field

BREACH DESCRIPTION

* indicates required field

  1. 7. If applicable, describe the safeguards in place at the time of the breach:

CONTAINMENT OF THE BREACH

* indicates required field

RISK EVALUATION

* indicates required field

  1. Personal or Personal Health Information Involved

* indicates required field

  1. Individuals Affected by the Breach

* indicates required field

  1. Harm from the Breach

  2. Yes No Unknown

NOTIFICATION


  1. Yes No


  2. Yes No


  3. Yes No


  4. Yes No

PREVENTION

ADDITIONAL INFORMATION