Privacy Breach Form

A privacy breach is the result of unauthorized access to, or collection, use, or disclosure of personal information. Such activity is unauthorized if it occurs in contravention to the Protection of Privacy Act. Some of the most common privacy breaches happen when personal information is stolen, lost, or mistakenly disclosed.

If you have discovered or are aware of a privacy breach, please fill out this form. You may also complete

privacy_breach_form_1_2019.pdf

and notify the Privacy Office (403-332-4620 ), so the breach can be contained and the risk can be assessed.

Contact Information

Name

Department/Unit

Phone

Format: (xxx)-xxx-xxxx

Date

Incident

Date of incident

Tme of incident

Was the incident reported? (If the incident was reported, please attach a copy of the incident report)

To whom and when was the incident reported?

Location of incident

Describe the incident

When was incident discovered

How was it discovered

What was the cause of the incident

Nature/Scope of Personal Information Involved

What personal information was involved (list all)

Who may be affected (e.g. students, faculty members, etc.)

How many individuals may be affected

What action has been taken

Message All information collected on this form is maintained by the University of Lethbridge Privacy Office to help respond to the breach.

Protection of Privacy

PRIVACY STATEMENT - The personal information collected on this form is for the purpose of investigating and responding to a report of the privacy breach contained herein. This collection is authorized by section 4(c) of the Alberta Protection of Privacy Act (POPA). For questions about the collection of personal information, contact the Privacy Officer, University of Lethbridge, 4401 University Drive West, Lethbridge, Alberta, T1K 3M4, privacy@uleth.ca, or 403-332-4620.

Privacy Breach Form

Students

Information for

Campus