NCDHHS Privacy and Security Office - Incident Reporting Form
Do not put confidential data in the initial ticket.
Fields marked with * are required.
For anonymous reporting:
Name - may be anonymous
Email - may be fictitious (or) use
[email protected]
Phone - may be fictitious (or) use 000-000-0000
Ensure information is accurate and all required fields are completed.
Click
"Submit"
. Note: Once submitted, the information is sent to the DHHS Privacy and Security Office.
If you have any questions, please contact the DHHS Privacy Security Office at
[email protected]
.
Reporter Name
*
Office Phone
*
Email
*
Address
City
State
Select...
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip
Division
*
Select...
Division of Aging and Adult Services
Division of Child Development and Early Education
Division of Child and Family Well-Being
Division of Health Service Regulations
Division of Health Benefits
Division of Medical Assistance
Division of Mental Health
Division of Public Health
Division of Services for the Blind
Division of Services for the Deaf and Hard of Hearing
Division of Social Services
Division of State Operated Healthcare Facilities
Division of Vocational Rehabilitation Services
Information Technology Division
LME\MCO\Business Associate
Division of Counsel of Developmental Disabilities
North Carolina Families Accessing Systems through Technology (NCFAST)
Office of Budget and Analysis
Office of Communications
Office of Government Affairs
Office of Human Resources
Office of NC TRACKS
Office of Procurement and Contract Services
Office of Property and Construction
Office of Rural Health
Office of the Controller
Office of the General Counsel
Office of the Internal Audit
Office of the Secretary
Privacy and Security Office
Other
Other
Priority:
*
Select...
Low
Medium
High
Incident Type:
*
Select...
Complaint
Fraud
HIPAA
Privacy
Security
Lost or Stolen asset
Business Continuity
Date/Time of Occurrence
*
[yyyy-mm-dd]
Summary of Incident:
*
If you are human, please
do not
use this field.