Get Breach Report Form - Tricare - Tricare

This guide provides clear instructions on how to complete the Breach Report Form for Tricare. By following the steps outlined below, users will gain an understanding of each section of the form to ensure accurate completion and submission.

Follow the steps to fill out the Breach Report Form accurately.

1. Press the ‘Get Form’ button to access the Breach Report Form. This will allow you to open the document in an editable format.
2. In the first section, input the date of the breach and the breach discovery date. These details are crucial for tracking the timeline of the incident.
3. Fill out the US-CERT number and the date reported to US-CERT. This identification number helps in the management and response to the breach.
4. Indicate whether this is the initial report to the TMA Privacy and Civil Liberties Office. If it is not the first report, provide the dates of previous reports in red text.
5. Complete the information for the DoD component or organization involved, including component name, organization, point of contact, title, telephone, and email.
6. If applicable, provide the details for the business associate involved, including name, address, point of contact, title, telephone, and email.
7. Provide contact information for the person who can be reached for further information regarding this report.
8. Indicate the total number of individuals affected by the breach and categorize the breakout number by government civilians, military (reserve, active), or others.
9. Answer whether individuals affected reside in the same state or jurisdiction if the total exceeds 500.
10. Select the types of incident involved by indicating if it includes paper records, equipment, e-mail, or other factors as needed.
11. Describe the type of personally identifiable information involved in the incident, including social security numbers, names, and health information.
12. Provide a concise description of the breach, actions taken in response, and the potential impact of the breach based on risk assessment.
13. Lastly, indicate if individual and media notices were provided. If person submitting the report is different, provide their contact details.
14. Once all fields are completed, ensure to save changes. You can download, print, or share the form as needed.

Complete your Breach Report Form online today to ensure proper documentation and response to incidents.