Breach of Personal Data Complaint Form

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Breach of Personal Data Complaint…

Lennoxville & District Community Aid is committed to protecting your privacy. We have improved and updated our personal data and information protection policy and reviewed our practices.

This form is to be used in cases when there is a (question of) breach of confidentiality.

This form is to report important details about an event that resulted in a breach of personal data managed by Lennoxville & District Community Aid. The information used in this report shall be used solely for recording purposes for the individual and following a request from the Quebec government.

We will respond to you within 15 business days.

PERSON INVOLVED IN THIS REPORT

Name:(Required)

First Last

Phone:(Required)

Email:(Required)

THE INCIDENT

Date of incident:(Required)

Time :

Describe how was the incident detected:(Required)

Describe the incident and how it was detected: (Max 250 words)(Required)

Was anything permanently impacted by the incident?(Required)

Yes

If yes, please describe:(Required)

Is there any other information you would like to include?(Required)

Yes

If yes, please describe: (Max 250 words)(Required)

Name

This field is for validation purposes and should be left unchanged.