Department Of The Navy (Don) Loss Or Compromise Of Personally Identifiable Information (Pii) Breach Reporting Form Page 2

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Complete Department Of The Navy (Don) Loss Or Compromise Of Personally Identifiable Information (Pii) Breach Reporting Form with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.

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MSG/DONCIO 291652ZFEB 2008

ORGANIZATION DESIGNATED OFFICIAL

19. Name:

20. Title:

21. Phone Number:

22. E-mail Address:

Individual Notifications:

Based on information provided in this report, a risk analysis will be conducted by the DON CIO Privacy Office. If the analysis leads to the

determination of a high risk potential for identity theft, this report's Organization Designated Official will be contacted within 24 hours and

provided with additional guidance regarding the requirement for notifying individuals.

SENIOR OFFICIAL SIGNING NOTIFICATION LETTERS (IF APPLICABLE) (Usually the Commanding Officer)

23. Name:

24. Title:

25. Phone Number:

26. E-mail Address:

Selecting this button will forward the breach report to: the US-CERT, the DON CIO

Submit Initial Report for SECNAV/NAVY Breaches

Privacy Office, OPNAV N6, and CHINFO.

Selecting this button will forward the breach report to: the US-CERT, the DON CIO

Submit Initial Report for MARINE CORPS Breaches

Privacy Office, CHINFO, the MC PA Officer (ARSF), the MC C4 Cy Division, the MCNOSC

Watch Officer, and the MC Public Affairs Media (PAM) Branch.

Selecting this button will forward the breach report to: the US-CERT, the DON CIO

Submit Initial Report for BUMED Breaches

Privacy Office, OPNAV N6, CHINFO, BUMED, and the Defense Health Agency (DHA).

Selecting this button will forward the breach report to: the DON CIO Privacy Office,

Submit Supplemental Report for SECNAV/NAVY Breaches

OPNAV N6, and CHINFO.

Selecting this button will forward the breach report to: the DON CIO Privacy Office,

Submit Supplemental Report for MARINE CORPS Breaches

CHINFO, the MC PA Officer (ARSF), the MC C4 CY Division, the MCNOSC Watch

Officer, and the MC Public Affairs Media (PAM) Branch.

Selecting this button will forward the breach report to: the DON CIO Privacy Office,

Submit Supplemental Report for BUMED Breaches

OPNAV N6, CHINFO, BUMED, and the Defense Health Agency (DHA).

If this form will not work with your version of Adobe Acrobat, please follow the procedure in DON CIO WASHINGTON DC 291652Z FEB 08 LOSS OF PERSONALLY IDENTIFIABLE

INFORMATION (PII) REPORTING PROCESS or MARINE CORPS ENTERPRISE INFORMATION ASSURANCE DIRECTIVE 011

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OPNAV 5211/13 (Rev Mar 2015)

PREVIOUS EDITIONS ARE OBSOLETE

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