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Name:
Email:
Priority:
Low
Medium
High
Who is affected:
Patients
Employees
Suppliers
Healthcare Partners
Unknown
Date the concern occurred (If known):
Date the concern was discovered:
Location / Department where the concern occurred:
Which best describes your concern:
Personal information was accessed without authorisation
Personal information was disclosed inappropriately
Personal information is being collected unnecessarily
Personal information is being retained longer than necessary
Personal information is inaccurate or not being corrected
Privacy policy or procedure is not being followed
Confidential conversations can be overheard
Physical records are not adequately secured
Electronic records are not adequately secured
I have concerns about CCTV/privacy monitoring
Another employee's privacy rights may have been violated
Has This Been Reported Previously:
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No
Unsure
Yes
Who and when was it reported to:
Subject:
Message:
Suggested knowledgebase articles:
The information provided is true and accurate to the best of my knowledge:
I confirm
Doctor On Call will use the information provided solely for investigating and resolving this privacy complaint in accordance with its Privacy Programme:
I understand
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