HIPAA Compliance Assessment Form
Complete this questionnaire to review your organization’s privacy, security, and operational practices related to HIPAA-style compliance assessment. Do not include sensitive medical or personal information.
Organization Details
Organization Name
*
Organization Type
*
Healthcare Provider
Business Associate
Vendor
Other
Primary Contact Name
*
Primary Contact Email
*
example@example.com
Assessment Readiness
Current assessment objective
*
Current compliance program status
*
Not started
In progress
Partially implemented
Mostly implemented
Established
Self-rated readiness score
*
1
2
3
4
5
Safeguards and Practices Review
Safeguard Areas Assessment
*
Rows
Not in place
Planned
Partially in place
Mostly in place
Fully in place
Policies and procedures
1
2
3
4
5
Workforce training
6
7
8
9
10
Access controls
11
12
13
14
15
Audit logging
16
17
18
19
20
Incident response
21
22
23
24
25
Vendor management
26
27
28
29
30
Data retention
31
32
33
34
35
Device and security practices
36
37
38
39
40
Follow-up Notes / Gaps Identified
Priority Follow-up Areas
Policies and procedures
Workforce training
Access controls
Audit logging
Incident response
Vendor management
Data retention
Device and security practices
Other
Submit
Should be Empty: