Human Resources | Kalamazoo College

HIPAA Violation Reporting Form

This form is used to report potential HIPAA Violations to ensure prompt investigation and resolution.

Date(Required)

Name

First Last

Department/Position

Phone

Description of HIPAA Violation

Please use this section to describe the HIPAA violation.

Date of Incident(Required)

Time of Incident(Required)

Description of Incident(Required)

Provide a detailed description of the HIPAA violation, including what happened, who was involved, and any potential consequences or impact on protected health information (PHI).

Type of PHI Involved(Required)

Specify the type(s) of PHI that were compromised or potentially compromised in the incident.]

Witnesses (if any)

List any witnesses to the incident, along with their contact information if available.

Immediate Actions Taken

Describe any immediate actions taken to address the HIPAA violation, such as containment measures or notifying management.

Additional Information:

Include any additional information that may be relevant to the investigation or resolution of the HIPAA violation.

Signature