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Unauthorized Data Disclosure or Breech Complaint Form

Required

Unauthorized Data Disclosure or Breech Complaint Form
Name of Person Filing This Reportrequired
Prefix (optional)
First Name
Last Name
I am a:required
Impacted Student or Employee NamerequiredIf this report is directly related to a student or employee data breech please complete this section
First Name
Last Name
If this report is directly related to a student or employee data breech please complete this section
Must contain a date in M/D/YYYY format
What is the approximate cause of the breach incident (please check all that apply)?required
Enter YES or NO. If YES please explain.