--- title: Completing The Breach Determination Assessment Form description: Completing The Breach Determination Assessment Form --- [Skip to content](https://knowledge.compliancygroup.com/home/home/legacy-completing-the-breach-determination-assessment-form#main-content) English - United States Show submenu for translations [Submit a Ticket](https://knowledge.compliancygroup.com/home/kb-tickets/new?hsLang=en-us) [Go To Customer Portal](https://help.compliancygroup.com/home?hsLang=en-us) ![Compliancy Group](https://knowledge.compliancygroup.com/hs-fs/hubfs/Compliancy%20Group%20Logo%20Full%20RBG-sized.png?width=300&height=54&name=Compliancy%20Group%20Logo%20Full%20RBG-sized.png) Open main navigation Close main navigation - English - United States Show submenu for translations - [Submit a Ticket](https://knowledge.compliancygroup.com/home/kb-tickets/new) - [Go To Customer Portal](https://help.compliancygroup.com/home) How can we help you? - There are no suggestions because the search field is empty. 1. [Help Center](https://knowledge.compliancygroup.com/home?hsLang=en-us) 2. [Legacy Guard Features](https://knowledge.compliancygroup.com/home/legacy-guard-features?hsLang=en-us) 3. [Incidents - Legacy](https://knowledge.compliancygroup.com/home/legacy-guard-features?hsLang=en-us#incidents-legacy) # Completing The Breach Determination Assessment Form The Department of Health and Human Services Office for Civil Rights requires Organizations to report Breaches affecting protected health information. Before completing the Breach Determination Assessment Form, please refer to the [Job Aid for Analysis of Security of PHI](https://knowledge.compliancygroup.com/home/support/solutions/articles/48001193188-job-aid-for-analysis-of-security-of-phi?hsLang=en-us) to determine whether or not the incident involved unsecured PHI.   Once you have completed the Breach Determination Assessment Form, please save it to your computer. The Breach Determination Assessment Form will need to be uploaded as evidence upon [submitting a new incident to the Guard Incident Manager](https://knowledge.compliancygroup.com/hubfs/Knowledge%20Base%20Import/Breach%20Determination%20Assessment%20Form%20copy.docx?hsLang=en-us). This Form will not be sent to the HHS, but is used to better determine if an Incident is, in fact, a Breach, for your records.   Once the Breach Determination Form is filled out, please contact [support@compliancygroup.com](mailto:support@compliancygroup.com) to schedule some time to discuss the Incident with our Audit Response Team.   [You can download the Breach Determination Assessment Form here.](https://app.hubspot.com/api/filemanager/api/v2/files/194063161733/signed-url-redirect?portalId=47667694)     - [Getting started](https://knowledge.compliancygroup.com/home/getting-started?hsLang=en-us#main-content) - [Onboarding](https://knowledge.compliancygroup.com/home/getting-started?hsLang=en-us#onboarding) - [Product Overviews](https://knowledge.compliancygroup.com/home/getting-started?hsLang=en-us#product-overviews) - [Workforce](https://knowledge.compliancygroup.com/home/workforce?hsLang=en-us#main-content) - [Policies](https://knowledge.compliancygroup.com/home/workforce?hsLang=en-us#policies) - [Settings Module](https://knowledge.compliancygroup.com/home/workforce?hsLang=en-us#settings-module) - [3rd Party Risk](https://knowledge.compliancygroup.com/home/3rd-party-risk?hsLang=en-us) - [Incident Management](https://knowledge.compliancygroup.com/home/incident-management?hsLang=en-us) - [Risks & Assessments](https://knowledge.compliancygroup.com/home/risks-assessments?hsLang=en-us) - [Healthcare Compliance](https://knowledge.compliancygroup.com/home/healthcare-compliance?hsLang=en-us#main-content) - [Privacy](https://knowledge.compliancygroup.com/home/healthcare-compliance?hsLang=en-us#privacy) - [Data Security](https://knowledge.compliancygroup.com/home/healthcare-compliance?hsLang=en-us#data-security) - [OSHA Workplace Safety](https://knowledge.compliancygroup.com/home/healthcare-compliance?hsLang=en-us#osha-workplace-safety) - [Clinical & Quality](https://knowledge.compliancygroup.com/home/healthcare-compliance?hsLang=en-us#clinical-quality) - [State Requirements](https://knowledge.compliancygroup.com/home/healthcare-compliance?hsLang=en-us#state-requirements) - [Fraud, Waste & Abuse](https://knowledge.compliancygroup.com/home/healthcare-compliance?hsLang=en-us#fraud-waste-abuse) - [Compliance Operations](https://knowledge.compliancygroup.com/home/healthcare-compliance?hsLang=en-us#compliance-operations) - [Legacy Guard Features](https://knowledge.compliancygroup.com/home/legacy-guard-features?hsLang=en-us#main-content) - [Admin - Legacy](https://knowledge.compliancygroup.com/home/legacy-guard-features?hsLang=en-us#admin-legacy) - [Assets - Legacy](https://knowledge.compliancygroup.com/home/legacy-guard-features?hsLang=en-us#assets-legacy) - [Documents - Legacy](https://knowledge.compliancygroup.com/home/legacy-guard-features?hsLang=en-us#documents-legacy) - [Incidents - Legacy](https://knowledge.compliancygroup.com/home/legacy-guard-features?hsLang=en-us#incidents-legacy) - [My Documents - Legacy](https://knowledge.compliancygroup.com/home/legacy-guard-features?hsLang=en-us#my-documents-legacy) - [My Tasks - Legacy](https://knowledge.compliancygroup.com/home/legacy-guard-features?hsLang=en-us#my-tasks-legacy) - [People - Legacy](https://knowledge.compliancygroup.com/home/legacy-guard-features?hsLang=en-us#people-legacy) - [Programs - Legacy](https://knowledge.compliancygroup.com/home/legacy-guard-features?hsLang=en-us#programs-legacy) - [Reports - Legacy](https://knowledge.compliancygroup.com/home/legacy-guard-features?hsLang=en-us#reports-legacy) - [The Dashboard - Legacy](https://knowledge.compliancygroup.com/home/legacy-guard-features?hsLang=en-us#the-dashboard-legacy) - [Training - Legacy](https://knowledge.compliancygroup.com/home/legacy-guard-features?hsLang=en-us#training-legacy) - [Vendors - Legacy](https://knowledge.compliancygroup.com/home/legacy-guard-features?hsLang=en-us#vendors-legacy) - [Account & Billing](https://knowledge.compliancygroup.com/home/account-billing?hsLang=en-us) - [The Guard Support](https://knowledge.compliancygroup.com/home/the-guard-support?hsLang=en-us#main-content) - [P&P Drafts](https://knowledge.compliancygroup.com/home/the-guard-support?hsLang=en-us#pp-drafts) - [Settings](https://knowledge.compliancygroup.com/home/the-guard-support?hsLang=en-us#settings) [![compliancy-group-logo-white](https://knowledge.compliancygroup.com/hs-fs/hubfs/compliancy-group-logo-white.png?width=200&height=37&name=compliancy-group-logo-white.png "compliancy-group-logo-white")](http://compliancy-group.com) Contact Us - [support@compliancygroup.com](mailto:support@compliancygroup.com) Copyright © 2026, Compliancy Group LLC Cookie Settings