SSBA Reporting Forms: Incident Report

Use this form if you are a Registered facility and you need to report an incident that is defined as a reportable event, whether it occurs intentionally or by accident.

Page last updated: 24 July 2014

SSBA Reporting Forms List

Release Date: July 2014

Please complete this form for the following incidents which are reportable events:

  • Loss of an SSBA.
  • Theft of an SSBA.
  • Attempted theft of an SSBA.
  • Unauthorised access to SSBAs or sensitive information relating to SSBAs.
  • Attempted unauthorised access to SSBAs or sensitive information relating to SSBAs.
  • Accidental release of SSBAs.
  • A person affected by an SSBA as a result of the entity handling the SSBA.

You can also use this form to report any temporary arrangements put in place when dealing with an emergency situation, such as, emergency maintenance to a facility. Please tick the “Other” box under Incident type and provide details.

Introduction

Registered facilities must report to the Department of Health (Health) all incidents that are defined as reportable events, whether they occur intentionally or by accident. You are required to submit this form as soon as possible and within two business days of the discovery of the incident.

Providing information to Health

The information you provide to Health is mandated by the National Health Security Act 2007 and will be included on the National Register of SSBAs.

It is important to answer all questions and to provide accurate information. If the information you provide is incorrect or incomplete, Health may require you to provide additional information. This may cause delays.

Privacy

Personal information provided to Health will comply with the requirements of the Privacy Act 1988.

Application Authorisation

Please ensure that the person completing this form holds the appropriate authority to submit this application on behalf of the entity or facility.

Instructions on preparing this notification

This document allows electronic entry of information into the required fields. It is recommended that, where possible, this form should be completed on a computer and a copy printed, signed and sent to Health.

All questions are mandatory and must be completed. If the space provided in each field is not sufficient to complete your answer, please include any additional information in an attachment with the information clearly marked as to which question it relates to.

Please ensure you retain a copy of this completed form as Health is unable to provide copies of submitted documents.

Lodgement

To lodge this form via post you will need to use an opaque envelope and post using Australia Post’s Registered Mail service. You are considered to have submitted the report at the date and time shown on the registered post receipt.

Please do not email or fax forms to Health as these cannot be accepted.

Please submit all postal applications to:

The Director
Health Emergency Countermeasures Section
Department of Health
MDP 140, GPO Box 9848
Canberra ACT 2601

Once Health has received the form, you will be provided with a confirmation of receipt by email to the contact officer listed for the facility.

Further Information

Please use your facility reference number to refer to any matters relating to your facility.

If you have any queries about this form please contact the SSBA Regulatory Scheme:

Telephone: (02) 6289 7477
Email: SSBA

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Part 1: Facility Details

Please complete the details for the entity and facility.

Facility registration number
Entity name
Facility name

Part 2: Incident Type

Please tick which incident is applicable. Please note that you will need to complete a separate incident report for each incident.

Loss of an SSBA

Theft of an SSBA

Unauthorised Access to an SSBA or Sensitive Information

Attempted Unauthorised Access to an SSBA or Sensitive Information

Accidental Release of an SSBA

A person affected by an SSBA as a result of the entity handling the SSBA

Other, please provide details in Part 3

Part 3: Incident Details

Please complete the table below providing details of the incident.

Incident Details
Date detected

Unknown

Date:

Date range: from: ------- to: -------

Location of incident (if known)

Brief description of the incident or event
SSBA (1) involved (if applicable)

Select SSBA

Specific strain, serotype or toxin subunit (if applicable)
SSBA (2) involved (if applicable) Select SSBA
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Part 4: Reporting

Please complete details of who you have reported the incident to.

Reported To Date Reported Order Reported Reference Number
Law Enforcement   Please Select Order

Department of Health Please Select Order

N/A

Part 5: Security Risk Management Plan

Please provide details regarding your security risk mangement plan.

Has your security risk management plan been updated in accordance with the SSBA Standards?

Yes

No

Action Plan
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Part 6: Signature

The information collected on this form may be used by the Department of Health to decide whether to vary the National Register of Security Sensitive Biological Agents (National Register). If a decision is made to vary the National Register, the information contained on this form, including personal information, will be recorded on the National Register by Health.

The information collected on this form is authorised under the National Health Security Act 2007 and National Health Security Regulations 2008. Information collected on this form may be disclosed by Health to the Australian Security Intelligence Organisation, law enforcement agencies such as the Australian Federal Police and State and Territory police forces, other agencies responsible for responding to emergencies and other specified persons. The Department is unlikely to disclose personal information to overseas recipients.

Health has an Australian Privacy Principles (APP) privacy policy which you can read. You can obtain a copy of the APP privacy policy by contacting Health by telephone on (02) 6289 1555, freecall 1800 020 103 or by using the online enquiries form.

The National Register is hosted and maintained by the Attorney-General’s Department.

I declare that:

  • I am duly authorised to sign this declaration on behalf of the entity associated with this facility;
  • The information supplied on this form and any attachment is true and correct; and
  • This entity is compliant with the SSBA Standards currently in force.
Signature
Date
Full name (Please print)
Position title
Contact telephone number
Contact e-mail address
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