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Privacy and Security Incident Reporting
Report a Potential Privacy or Security Incident
Report a Potential Privacy or Security Incident
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Incidents may be reported anonymously but the lack of contact information may hinder follow up investigation activity.
To enter an ANONYMOUS report, please ensure you have not signed into the Services Portal. If you see your name in the top right, click on it and select "Sign Out" and then return to this page.
Scroll to the bottom of this form and enter "anonymous" for first name and last name then enter "anonymous@pacificu.invalid" as the email address. Do not enter a phone number.
Do you acknowledge that you will not delete any files, emails, voicemails or printed material until directed to by the Privacy Officer?
Do you acknowledge that you will not delete any files, emails, voicemails or printed material until directed to by the Privacy Officer?
Yes
Short Description
A short description to explain the nature of a ticket.
Date and time the incident was discovered
(mm/dd/yyyy hh:mm)
Location where the event occurred
Have you notified your supervisor of this incident?
No
Yes
Application(s) or Biomedical Instrument Involved
Application(s) or Biomedical Instrument Involved
AxiUm
BioMedical Device
Compulink Cloud
Compulink Legacy (For Viewing Historical Records)
CounselEar
Epic
Harmony
Pacific University Email
Private Email
Other issue (software, device, security, or privacy)
Biomedical Instrument Clinic Name and Location
Biomedical Instrument Name
Clinic name and location of other software or device
Number of patients involved
Number of patients involved
No patients involved
One patient involved
Two patients involved
Three or more patients involved
Patient One Name
Patient One Date of Birth
(mm/dd/yyyy)
Patient One Medical Record Number
Patient Two Name
Patient Two Date of Birth
(mm/dd/yyyy)
Patient Two Medical Record Number
Patient Three Name
Patient Three Date of Birth
(mm/dd/yyyy)
Patient Three Medical Record Number
Additional Details
Please provide additional details of the incident not reported above. Include what happened, when it happened, and how it happened.
Press Alt + 0 within the editor to access accessibility instructions, or press Alt + F10 to access the menu.
Attachment
Include any files associated with your report.
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Incidents may be reported anonymously but the lack of contact information may hinder follow up investigation activity.
To enter an ANONYMOUS report, please ensure you have not signed into the Services Portal. If you see your name in the top right, click on it and select "Sign Out" and then return to this page.
Scroll to the bottom of this form and enter "anonymous" for first name and last name then enter "anonymous@pacificu.invalid" as the email address. Do not enter a phone number.
Other Fields
Your name
Your first name
Your last name
Your email address
Your phone number
Verification Code