internal_breach_protocol.md

Internal Data Breach Notification Protocol

This document outlines the procedure for responding to a suspected or confirmed data breach involving the Clarityops Augmented Decision AI. All personnel must adhere to this protocol.

Step 1: Immediate Identification and Containment

Action: As soon as a potential breach is identified, the first priority is to contain it.

• The responding team member must immediately notify the designated Privacy Officer and a lead engineer.
• Take immediate steps to isolate the affected system(s) to prevent further data loss. This may include revoking access credentials, taking a server offline, or disabling a feature.
• Preserve all logs and evidence related to the incident. Do not delete or alter any data.

Step 2: Preliminary Assessment

Action: The Privacy Officer will lead an assessment to determine the nature and scope of the breach.

• What happened? Determine the cause and timeline of the incident.
• What data was involved? Identify the type of data accessed (e.g., user prompts, usage data). Confirm whether any PHI was potentially exposed, contrary to our policy.
• Who is affected? Determine which users or organizations are impacted.
• What is the risk? Evaluate the "real risk of significant harm" to individuals based on the sensitivity of the data and the probability of misuse. This is the legal threshold for mandatory notification under PIPEDA.

Step 3: Notification (If Required)

Action: If the assessment determines there is a real risk of significant harm, the Privacy Officer will initiate notifications.

• Report to Privacy Commissioners: File a breach report with the Office of the Privacy Commissioner of Canada and any applicable provincial commissioners as soon as feasible.
• Notify Affected Individuals: Notify the affected individuals directly, in writing. The notification must contain sufficient information to allow them to understand the significance of the breach and to take steps to mitigate the harm.
• Notify Affected Organizations: If the data belongs to a partner organization (e.g., a hospital), notify them according to the terms of your agreement.

Step 4: Remediation and Post-Mortem

Action: After the breach is contained and notifications are complete, a full review must be conducted.

• The engineering team will identify and patch the vulnerability that led to the breach.
• The Privacy Officer will lead a post-mortem review to document the incident, the response, and lessons learned.
• Update security policies, procedures, and technical safeguards based on the findings to prevent a recurrence.