For use by the following organizations reporting a theft, loss or unauthorized use or disclosure (or unauthorized collection by means of the EHR) of personal information or personal health information (as applicable) to the Information and Privacy Commissioner of Ontario (IPC):
Health information custodians and coroners under the Personal Health Information Protection Act, 2004
Institutions under the Freedom of Information and Protection of Privacy Act or the Municipal Freedom of Information and Protection of Privacy Act
Child and family service providers under the Child, Youth and Family Services Act, 2017
Important Note: Do not include any personal information or personal health information with this form.
The IPC recognizes that the investigation, containment, and remediation of this privacy breach may not be complete at the time this form is submitted. Please provide as much of the requested information as is presently known.
The IPC may request additional information after reviewing this form.