PHI Risk Assessment Form
Please complete this form to evaluate the risks related to protected health information.
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Organization Name
*
Department/Unit
*
Please Select
Medical Records
Radiology
Laboratory
Billing
Admin
Other
Description of Data Handled
*
Risks Identified in Data Handling
*
Unauthorized Access
Data Leakage
Data Loss
Misuse of Data
Other
Data Storage Location
*
Please Select
On-premises
Cloud
Hybrid
Current Security Measures
*
Potential Vulnerabilities
*
Likelihood of Risk Occurrence
*
Low
Moderate
High
Impact Severity if Risk Materializes
*
Low
Moderate
High
Submit
Should be Empty: