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Breach of confidentiality report form
Fields marked with an asterisk (*) are mandatory.
Form
First name*
Last name*
Phone number*
Email address*
Type of report
Nature of the violation report
Victim
Witness
Person responsible
Message
Describe to us the violation that you suspect, witness or are responsible for
Are any third parties involved??
Are there any third parties involved??
Yes
No
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By checking this box, I certify that the information provided in this form is accurate and complete and I consent to its use for data protection purposes.
