Privacy Incident Report Form
This form allows you to report a known or suspected violation of health information privacy, security, and/or University policy at the University of Minnesota. We will collect the information about the incident and submit it to the appropriate party for further investigation and follow up.

By default, the information collected through this form is anonymous, and you are not required to submit your name or any contact information. However, should you wish us to follow up with you directly, you have the option of including your name, telephone number, and e-mail address where we can reach you.

Note: Please do not enter any PHI into this form.
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Name *
Phone
Email *
Organization
Department, Clinic, College, etc.
Where did the incident occur? *
When did the incident occur? *
When was the incident discovered? *
Describe the incident in detail, but do not include Protected Health Information. *
Protected Health Information includes, but is not limited to, patient names, Social Security numbers, or specific medical information.

What health information was involved in the incident?

 *
Required

What was the format of the information in the incident?

 *
Required

Other than the patient, who was involved in the incident? How were they involved?

 *
If known, please include names, title/positions, contact information.

Who has been notified or is aware of this incident?

 *
Include names, titles, and contact information. If the patient is not aware of the incident, DO NOT inform them without instruction from HIPCO.

Does this incident involve a research study? If so, please provide the study’s protocol number.

 *
If you answered yes to the previous question, was an RNI submitted for this incident? If so, please provide the RNI number. *

What happened to the PHI? What immediate remedial actions have been taken, if any?

 *

Is there any known impact or outcome of this incident? If so, please describe.

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