Administrative Procedure 194: Privacy Breach Protocol

Legal References

Municipal Freedom of Information and Protection of Privacy Act; Personal Health Information Protection of Privacy Act; Personal Information Protection and Electronic Documents Act

Related References

Information and Privacy Commissioner/Ontario, Breach Notification Assessment Tool, December 2006; Information and Privacy Commissioner/Ontario, What to do if a Privacy Breach Occurs: Guidelines for Government Organizations, May 2003; The Office of the Chief Information and Privacy Officer, Taking the Right Steps – A Guide to Managing Privacy and Privacy Breaches, revised April 18, 2007

1. Definition of a Privacy Breach

A privacy breach occurs when personal information is compromised, that is, when it is collected, used, disclosed, retained, or destroyed in a manner inconsistent with privacy legislation. Ontario school boards/authorities are governed by the following privacy statutes: Municipal Freedom of information and Protection of Privacy Act (MFIPPA), Personal Health Information Protection Act (PHIPA), and Personal Information Protection and Electronic Documents Act (PIPEDA).

Schools shall post Appendix A Responding to a Suspected Privacy Breach in all school offices and staff rooms.

Personal information can be compromised in many ways. Some breaches have relatively simple causes and are contained, while others are more systemic or complex.
The following are some examples of privacy breaches:
  Student Records Employee Records Business Records
of personal
Two teachers discussing (and identifying) a student in the local grocery store.

Student’s report card mailed to the wrong
home address.

Digital images of individuals taken and
displayed without consent.

Hard-copy psychological assessments kept in openly accessible file cabinets that are not secured or controlled.
Confidential student health records
inadvertently blown out of a car trunk and
scattered over a busy street.
Employee files containing social insurance numbers left in unlocked boxes near the open shipping/receiving area.

Budget reports (containing employee
numbers and names) found in their entirety in recycle bins and garbage bins.

Theft from car of a briefcase containing a
list of home addresses of teaching staff.
A list of names, including credit card numbers, left on the photocopier.

Personal information disclosed to trustees who did not need it to effectively decide on a matter.

Technology/computer error
Lost memory key containing student data.

Theft from teacher’s car of a laptop containing Special Education student records on the hard drive.
Sending very sensitive personal information to an unattended, open area printer.

Password written on a sticky note stuck to a monitor.

Resumes faxed or emailed to a wrong
destination or person.
Stolen laptop containing names and addresses of permit holders.

Tender information scanned and not cleared from multifunctional office

Disposal of equipment with memory capabilities (e.g., memory keys, disks,
laptops, photocopiers, fax machines, or cell phones) without secure destruction
of the personal information it contains.

2. Roles and Responsibilities in Responding to Privacy Breaches

The following personnel may need to be involved when responding to a privacy breach. Some of the following roles and responsibilities may be undertaken concurrently.
Individuals Roles Responsibilities
All school board employees need to be alert to the potential for personal information to be compromised, and therefore potentially play a role in identifying, notifying, and containing a breach.
Employees dealing with student, employee and/or business records need to be particularly aware of how
to identify and address a privacy breach.

All school board employees have the responsibility to:
  • notify their supervisor immediately, or, in their absence, their school boards/authority’s FOI Coordinator upon becoming aware of a breach
    or suspected breach;
  • contain, if possible, the suspected breach by suspending the process or activity that caused the breach.
Senior Administration, Managers, and Principals
Senior administration, managers, and principals are responsible for alerting the FOI Coordinator of a
breach or suspected breach and will work with the coordinator to implement the five steps of the response protocol.
Senior administration, managers, and principals have the responsibility to:
  • obtain all available information about the nature of the breach or suspected breach, and determine
    what happened;
  • alert the FOI Coordinator and provide as much information about the breach as is currently available;
  • work with FOI Coordinator to undertake all appropriate actions to contain the breach;
  • ensure details of the breach and corrective actions are documented.
FOI Coordinator
The FOI Coordinator plays a central role in the response to a breach by ensuring that all five steps of the
response protocol are implemented (see pages 4-6 for more details).
The FOI Coordinator will follow the following five steps (see page 4–6 for more details).
Step 1 – Respond
Step 2 – Contain
Step 3 – Investigate
Step 4 – Notify
Step 5 – Implement Change
Third Party Service Providers
Increasingly, school boards use contracted third party service providers to carry out or manage programs or services on their behalf.

Typical third party service providers are commercial school photographers, bus companies, external data warehouse services, outsourced administrative services
(such as cheque production, records storage and shredding), Children’s Aid Societies (CAS), Public Health Units (PHU), external researchers, and external consultants.

In such circumstances, school boards/authorities retain
responsibility for protecting personal information in accordance with privacy legislation.

Therefore, third party service providers need to know their roles and responsibilities if a privacy breach occurs when they have custody of personal information.

All third party service providers must take reasonable steps to monitor and enforce their compliance with the
privacy and security requirements defined in the contracts or service agreements, and are required to
inform their respective school boards of all actual and suspected privacy breaches.
The third party service providers have the responsibility to:
  • inform the school board contact as soon as a privacy breach or suspected breach is discovered;
  • take all necessary actions to contain the privacy breach as directed by the school board;
  • document how the breach was discovered, what corrective actions were taken and report back;
  • undertake a full assessment of the privacy breach in accordance with the third party service providers’
    contractual obligations;
  • take all necessary remedial action to decrease the risk of future breaches;
  • fulfill contractual obligations to comply with privacy legislation.
  • work with FOI Coordinator to undertake all appropriate actions to contain the breach and assess notification responsibilities

3. Response Protocol: Five Steps Implemented by the FOI Coordinator in Consultation with Senior Management

Initiate steps 1-3 as soon as a privacy breach or suspected breach has been reported.

Step 4 and 5 should be done in consultation with Senior Administration and the FOI Coordinator:

Step 1 – Respond

  • Assess the situation to determine if a breach has indeed occurred;
  • When a privacy breach is identified by an internal or external source, contact the appropriate area to respond to the breach;
  • Provide advice on appropriate steps to take to respond to the breach;
  • Report the privacy breach to key persons including the Director of Education or designate and, if necessary, to law enforcement; and
  • Evaluate effectiveness of response to the breach and implement improvement as necessary.

Step 2 – Contain

  • Identify the scope of the breach and contain it (e.g., retrieve the hard copies of any personal information that has been disclosed, determine if the breach would allow
    unauthorized access to any other personal information [e.g., electronic information system], change passwords and identification numbers and/or temporarily shut down the system if necessary to contain the breach);
  • Document the breach and containment activities;
  • Develop briefing materials; and
  • Brief the accountable decision maker, senior management, and key persons on the privacy breach and how it is being managed.

Step 3 – Investigate

Once the privacy breach is contained:
  • Conduct an investigation with the involvement of other parties as necessary:
    - Identify and analyze the events that led to the privacy breach;
    - Evaluate what was done to contain it; and
    - Recommend remedial action so future breaches do not occur.
  • Document the results of internal investigation and use the privacy breach checklist for record keeping, including:
    - background and scope of the investigation;
    - legislative implications;
    - how the assessment was conducted;
    - source and cause of the breach;
    - inventory of the systems and programs affected by the breach;
    - determination of the effectiveness of existing security and privacy policies, procedures, and practices;
    - evaluation of the effectiveness of the Ontario school board’s/authority’s response to the breach;
    - findings including a chronology of events and recommendations of remedial actions; and
    - the reported impact of the privacy breach on those individuals whose privacy was compromised.

Step 4 – Notify (Step 3 and Step 4 may happen concurrently)

  • Notify, as required, the individuals whose personal information was disclosed. The purpose of providing notice of a privacy breach to the individuals whose personal
    information was involved in the incident is to provide them with information about:
    - what happened;
    - the nature of potential or actual risks or harm;
    - what mitigating actions the board is taking;
    - appropriate action for individuals to take to protect themselves against harm.

The following factors should be considered when determining whether notification is required:
  • Risk of Identity Theft
    Is there a risk of identity theft or other fraud in your Ontario school board/authority? How reasonable is the risk? Identity theft is a concern if the breach includes unencrypted information such as names in conjunction with social insurance numbers, credit card numbers, driver’s license numbers, personal health numbers, debit card numbers with password information, or any other information that can be used for fraud by third parties (e.g., financial).
  • Risk of Physical Harm
    Does the loss or theft of information place any individual at risk of physical harm, stalking, or harassment?
  • Risk of Hurt, Humiliation, or Damage to Reputation
    Could the loss or theft of information lead to hurt, humiliation, or damage to an individual’s reputation? This type of harm can occur with the loss or theft of information
    such as mental health records, medical records, or disciplinary records.
  • Risk of Loss of Business or Employment Opportunities
    Could the loss or theft of information result in damage to an individual’s reputation, affecting their business or employment opportunities?

Step 5 – Implement Change

When determining what changes and remedial actions need to be implemented, consider whether it is necessary to:
  • review the relevant information management systems to enhance compliance with privacy legislation;
  • amend or reinforce the existing policies, procedures, and practices for managing and safeguarding personal information;
  • develop and implement new security or privacy measures, if required;
  • review employee training on legislative requirements, security and privacy policies, procedures, and practices to reduce potential or future breaches, and strengthen as
    required; and
  • test and evaluate remedial actions to determine if they have been implemented correctly and if policies, procedures, and practices need to be modified.


Privacy is…….…the right to control access to your personal information, and the right to decide what and how much information you give to others, who it is shared with, and for what purposes.

A PRIVACY BREACH occurs when……..personal information is collected, used, disclosed, retained or destroyed in a manner that does not meet privacy requirements set out in the federal and provincial privacy legislation.

Examples of privacy breaches may include, but are not limited to: memory key/jump drive left in a public area containing student data; laptop lost or stolen containing student records on the hard drive; documents containing student or employee personal information left unattended on a photocopier; reports containing employee personal information found un-shredded in recycle bins or garbage bins; confidential documents left in public view on an employee’s desk or other publicly accessible area.

If you suspect a PRIVACY BREACH has occurred, YOU are encouraged to:

…..notify your Supervisor immediately or, in their absence, the School Board’s Freedom of Information Coordinator at 519-527-0111 Ext 111; …..contain, if possible, the suspected breach by delaying or stopping the process or activity involving the exposure or mishandling of student or employee personal information.
Revised June 2015