Breach Investigation and Notification

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2026.1

In the case of a breach, Changineers shall notify all affected Customers. It is the responsibility of the Customers to notify affected individuals.

Policy Statements

Changineers policy requires that:

(a) Breach notification procedures are invoked upon confirmation of security breach that results in unauthorized disclosure of unprotected/unencrypted sensitive data.

(b) Individuals impacted by a confirmed data breach must be notified within a predefined, required timeframe of discovery of such breach.

Controls and Procedures

Breach Investigation Process

1. Discovery of Breach: A data breach shall be treated as “discovered” as of the first day on which such breach is known to the organization, or, by exercising reasonable diligence would have been known to Changineers (includes breaches by the organization’s Customers, Partners, or subcontractors). Changineers shall be deemed to have knowledge of a breach if such breach is known or by exercising reasonable diligence would have been known, to any person, other than the person committing the breach, who is a workforce member or Partner of the organization. Following the discovery of a potential breach, the organization shall begin an investigation (see organizational policies for security incident response and/or risk management incident response) immediately, conduct a risk assessment, and based on the results of the risk assessment, begin the process to notify each Customer affected by the breach. Changineers shall also begin the process of determining what external notifications are required or should be made (e.g., Secretary of Department of Health & Human Services (HHS), media outlets, law enforcement officials, etc.)

2. Breach Investigation: The Changineers Security Officer shall name an individual to act as the investigator of the breach (e.g., privacy officer, security officer, risk manager, etc.). The investigator shall be responsible for the management of the breach investigation, completion of a risk assessment, and coordinating with others in the organization as appropriate (e.g., administration, security incident response team, human resources, risk management, public relations, legal counsel, etc.) The investigator shall be the key facilitator for all breach notification processes to the appropriate entities (e.g., HHS, media, law enforcement officials, etc.). All documentation related to the breach investigation, including the risk assessment, shall be retained for a minimum of seven years. A breach log is kept and maintained by the Security and Privacy Officer.

3. Risk Assessment: A risk assessment is performed in accordance to applicable laws and regulations.

4. Timeliness of Notification: Upon discovery of a breach, notice shall be made to the affected Changineers Customers, usually within 24-48 hours but no later than 10 calendar days after the discovery of the breach. It is the responsibility of the organization to demonstrate that all notifications were made as required, including evidence demonstrating the necessity of delay.

5. Delay of Notification Authorized for Law Enforcement Purposes: If a law enforcement official states to the organization that a notification, notice, or posting would impede a criminal investigation or cause damage to national security, the organization shall:

   • If the statement is in writing and specifies the time for which a delay is required, delay such notification, notice, or posting of the timer period specified by the official; or
   • If the statement is made orally, document the statement, including the identify of the official making the statement, and delay the notification, notice, or posting temporarily and no longer than 30 days from the date of the oral statement, unless a written statement as described above is submitted during that time.

6. Content of the Notice: The notice shall be written in plain language and must contain the following information:

   • A brief description of what happened, including the date of the breach and the date of the discovery of the breach, if known;
   • A description of the types of unsecured protected health information that were involved in the breach (such as whether full name, Social Security number, date of birth, home address, account number, diagnosis, disability code or other types of information were involved), if known;
   • Any steps the Customer should take to protect Customer data from potential harm resulting from the breach.
   • A brief description of what Changineers is doing to investigate the breach, to mitigate harm to individuals and Customers, and to protect against further breaches.
   • Contact procedures for individuals to ask questions or learn additional information, which may include a toll-free telephone number, an e-mail address, a web site, or postal address.

7. Methods of Notification: Changineers Customers will be notified via email and phone within the timeframe for reporting breaches, as outlined above.

8. Maintenance of Breach Information/Log: As described above and in addition to the reports created for each incident, Changineers shall maintain a process to record or log all breaches of unsecured sensitive data regardless of the number of records and Customers affected. The following information should be collected/logged for each breach (see sample Breach Notification Log):

   • A description of what happened, including the date of the breach, the date of the discovery of the breach, and the number of records and Customers affected, if known.
   • A description of the types of unsecured protected health information that were involved in the breach (such as full name, Social Security number, date of birth, home address, account number, etc.), if known.
   • A description of the action taken with regard to notification of patients regarding the breach.
   • Resolution steps taken to mitigate the breach and prevent future occurrences.

9. Workforce Training: Changineers shall train all members of its workforce on the policies and procedures with respect to sensitive data as necessary and appropriate for the members to carry out their job responsibilities. Workforce members shall also be trained as to how to identify and report breaches within the organization.

10. Complaints: Changineers must provide a process for individuals to make complaints concerning the organization’s patient privacy policies and procedures or its compliance with such policies and procedures.

11. Sanctions: The organization shall have in place and apply appropriate sanctions against members of its workforce, Customers, and Partners who fail to comply with privacy policies and procedures.

12. Retaliation/Waiver: Changineers may not intimidate, threaten, coerce, discriminate against, or take other retaliatory action against any individual for the exercise by the individual of any privacy right. The organization may not require individuals to waive their privacy rights under as a condition of the provision of treatment, payment, enrollment in a health plan, or eligibility for benefits.

Changineers Platform Customer Responsibilities

The following requirements and guidelines shall be provided to and agreed upon by a client organization using Changineers platform to host sensitive data such as PII.

The agreement may be in the form of a contract or acceptance of terms and conditions.

1. The Changineers Customer that accesses, maintains, retains, modifies, records, stores, destroys, or otherwise holds, uses, or discloses unsecured sensitive data shall, without unreasonable delay and in no case later than 72 hours after discovery of a breach, notify Changineers of such breach. The Customer shall provide Changineers with the following information:

   • A description of what happened, including the date of the breach, the date of the discovery of the breach, and the number of records and Customers affected, if known.
   • A description of the types of unsecured protected health information that were involved in the breach (such as full name, Social Security number, date of birth, home address, account number, etc.), if known.
   • A description of the action taken with regard to notification of patients regarding the breach.
   • Resolution steps taken to mitigate the breach and prevent future occurrences.

2. Depending on the nature of the breach, an investigation may be conducted by Changineers or the Customer or jointly to determine the cause of breach.

3. Notice to Media: Unless Changineers is directly at fault for the cause of breach, Changineers Customers are responsible for providing notice to prominent media outlets at the Customer’s discretion.

4. Notice to Authorities: Unless Changineers is directly at fault for the cause of breach, Changineers Customers are responsible for providing notice to the appropriate authorities, including the Secretary of Health and Human Services (HHS) and your Lead Supervisory Authority (LSA) under GDPR, at the Customer’s discretion.

Sample Letter to Customers in Case of Breach

[Date]

[Name] [Name of Customer] [Address 1] [Address 2] [City, Postal Code] [State]

Dear [Name of Customer]:

I am writing to you from Changineers Pty Ltd, with important information about a recent breach that affects your account with us. We became aware of this breach on [Insert Date] which occurred on or about [Insert Date]. The breach occurred as follows:

Describe event and include the following information:

• A brief description of what happened, including the date of the breach and the date of the discovery of the breach, if known.
• A description of the types of unsecured protected health information that were involved in the breach (such as whether full name, Social Security number, date of birth, home address, account number, diagnosis, disability code or other types of information were involved), if known.
• Any steps the Customer should take to protect themselves from potential harm resulting from the breach.
• A brief description of what Changineers is doing to investigate the breach, to mitigate harm to individuals, and to protect against further breaches.
• Contact procedures for individuals to ask questions or learn additional information, which includes a toll-free telephone number, an e-mail address, web site, or postal address.

Other Optional Considerations:

• Recommendations to assist customer in remedying the breach.

We will assist you in remedying the situation.

Sincerely,

James Gregory
Security Officer
Changineers Pty Ltd
security@changineers.com.au

List of Contacts for Authorities

Australian Information Commissioner and Privacy Commissioner

Entities must prepare and give a copy of the statement to the Commissioner as soon as practicable after becoming aware of the eligible data breach (s 26WK(2)).

The OAIC has an online form for entities to lodge all eligible date breach statements under section 26WK of the Privacy Act.

If you are unable to use the online form, please contact the OAIC enquiries line to make alternative arrangements.

• Phone: 1300 363 992
• Email: enquiries@oaic.gov.au

Revision History

Date	Summary	Approved by
2020-01	Initial revision.	James Gregory