First Name(s) *
Surname *
E-mail *
Contact telephone number
Incident Description
DO NOT enter any Personal Identifiable Data (PID)
What happened?
How many people have seen the breach / information?
Was this from email /post / printer / computer screen?
What organisation(s) are involved / affected?
What action has been taken?
Date of Incident
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Time of Incident (24-Hour)
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What type of data was breached?
Address and/or postcode
Biometric data
Data given in confidence
Date of Birth
Genetic data
Health: Physical, mental or condition
NHS number
Name
Personal email address
Political opinions
Private/secret information
Racial or ethnic origin
Religious beliefs or other similar beliefs
Sexual life
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Adverse Event
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Breach of patient confidentiality: BRCH
Breach of confidentiality of staff records or information: HR
Breach of sensitive business information: FINBRCH
Patient incorrectly identified: PATID
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Is BOB ICB the source or recipient of the breach?
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Source
Recipient
Both
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If both, please provide more details:
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Who is the source? (please specify job role and department. Do NOT include names)
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Who is the recipient? (please specify job role and department. Do NOT include names)
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Where data has been sent inappropriately, has the receipient been informed?
Select an Option
Yes
No
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Can you confirm that it has not been shared further?
Select an Option
It has been shared
It has not been shared
I am not sure it has been shared
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If it has been shared, please provide more details:
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If you are not sure it has been shared, please provide more details:
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Number of data subjects affected (please estimate)
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