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Report a Data Breach

1Before You File

2Your Information

3Entity That Experienced the Breach

4Breach Details

5Date Details

6Upload Documents

7Confirmation

8Review

Please select one of the following to proceed(Required)

You are a private person or business reporting a data breach pursuant to 73 P.S. § 2303(c.1).

You are a Pennsylvania government agency or entity reporting a data breach pursuant to 73 P.S. § 2303(a.1).

Name(Required)

First Last

Title

Your Firm/Organization Name(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Email(Required)

Enter Email Confirm Email

Phone(Required)

Entity that experienced the Breach

Entity Name(Required)

Hidden

Entity Name(Required)

First Last

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Email Address

Phone Number

Website

Organization Type(Required)

Breach Details

Description of Breach (Select All That Apply)(Required)

External systems breach (I.e. Hacking)

Inadvertent disclosure

Insider wrongdoing

Internal systems breach

Loss of device, documentation or media

Theft of device, documentation or media

Unauthorized access (not including theft, loss or hacking)

Other

Type of External Hacking

Description of Breach (Other)

Information Accessed/Acquired (Select All That Apply)(Required)

Social Security Number

Driver License Number/ Non-Driver ID

Financial account information (including payment cards)

Username/ email address and password

Unknown/ not determined

Health insurance information

Medical information in the possession of a State Agency or State Agency Contractor

Other

Is the entity a “Covered Entity” required to provide notice to the U.S. Department of Health and Human Services under 45 C.F.R § 164-408?(Required)

Yes

Total number of persons affected (including Pennsylvania residents)(Required)

Pennsylvania State residents(Required)

Do you believe that this security breach was part of a larger breach that likely affected other organizations?(Required)

Yes

Have the Consumer Reporting Agencies been notified?(Required)

Yes

Breach Date Details

Start Date(Required)

MM slash DD slash YYYY

End Date(Required)

MM slash DD slash YYYY

Date learned of unauthorized access to network(Required)

MM slash DD slash YYYY

Date learned private information was accessed and acquired(Required)

MM slash DD slash YYYY

Date affected Pennsylvania residents were notified(Required)

MM slash DD slash YYYY

Manner of notification to affected persons (Select All That Apply)

Written

Electronic

Telephone

Substitute notice

List dates of any previous (within 12 months) breach notifications

Identity theft protection service offered?(Required)

Yes

Summary of incident(Required)

Upload Documents

Do you have supporting documents?

Yes

Upload your supporting documments

Drop files here or

Accepted file types: jpg, gif, png, pdf, Max. file size: 100 MB, Max. files: 25.

In filing this report, I understand that:

End(Required)

The Attorney General may share information contained in this notification with other state, local and/or federal government agencies to coordinate law enforcement. In addition, the Attorney General may use information contained in this notification in legal proceedings to establish violations of law.

Untitled(Required)

I understand that any false statement made in connection with this report was made pursuant to and under penalty of 18 Pa.C.S. § 4904, relating to unsworn falsification to authorities.

Untitled(Required)

By typing my full name below, I certify that the above complaint is true and accurate to the best of my knowledge and that all documents attached are true and accurate copies of the originals.

Signature

Todays Date

MM slash DD slash YYYY

Are you human?

Bureau of Consumer Protection
15th Floor, Strawberry Square
Harrisburg, PA 17120

800-441-2555

Learn about the Breach of Personal Information Notification Act (“BPINA”)

It is not necessary to call and check the status of your complaint; you will be notified by mail when we receive information regarding your case. Please refrain from calling for “status reports,” though we encourage consumers to contact us as soon as possible should they have additional information regarding their complaint.