Travis County Incident/Complaint Form

**This form must be completed by the individual who discovered the incident. No third party reporting will be accepted.**

The Health Information Portability and Accountability Act (HIPAA) of 1996, allows individuals the right to report an incident or file a complaint about our privacy policies and procedures or if you believe we have violated yours or another person’s privacy rights. When an incident/complaint is received, the HIPAA Compliance and Privacy Office will come to an appropriate resolution within 45 - 60 days. Depending on the circumstances, this may take longer. Travis County Government will not engage in any discriminatory or other retaliatory behavior against you because of an incident reported or complaint.

Please complete as much information as possible. If you have any questions regarding this form, you may contact our HIPAA Compliance and Privacy Office (CAP) at (512) 854-1114 or email the form to privacy@traviscountytx.gov.

Would you like to remain anonymous?*

YesNo

Your Name

First NameLast Name

Best Contact Number

Your Fax Number

Travis County Email or Best Email Address

Are you an internal staff member or an external client or vendor?*

YesNo

Does this Incident/Complaint involve HIPAA Protected Health Information (PHI) or Personally Identifiable Information (PII)?

YesNo

What type of Incident are you reporting?

Please list out the PHI/PII identifiers:

Department or Business Unit Involved

Date of Discovery

Description Summary of Incident/Complaint

Describe in detail the facts pertaining to this Incident/Complaint and why you think it needs to be reported.

Please upload supporting documentation:

Note: All attachments are secure.

Are there any Travis County devices that may need to be analyzed or suspended?

YesNo

Tag Number

This can be found in SAP under Self Service Approvals, Most frequently used, “Assets.

Known Individuals Involved in Incident/Complaint

Other Witnesses Aware of Incident/Complaint That May Need to Be Contacted

Is this an internal issue?

YesNo

Have you contacted the Help Desk?

YesNo

Ticket Number

Current Date

Please verify that you are human.*

Travis County Incident/Complaint Form

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