Privacy & Security Department Self-Assessment

Conducting Department Self-Assessments

Department Self-Assessment Form - Login with your Active Directory credentials.

Reasons for conducting Privacy and Information Security Self Assessments

Important Instructions

The Department Self-Assessment can be completed over multiple sessions, but you must press the “Save for Later” button at the top or bottom of the form. An automatic email will be generated which contains the link to the form.

Original form submissions will be saved as a baseline and may be used as the starting point for upcoming years’ assessments. Alternatively, the department may choose to fill out a new form each year.

Individual submissions are tied to a User’s Active Directory credentials, so submissions can only be retrieved or updated by the original submitter.

Timelines for Conducting Self-Assessments

All departments including Physician Groups and Outpatient Clinics must conduct and complete routine (annual) assessments between January 1^st and October 31^st of each year.

General Instructions:

How is the Department Self-Monitoring and Assessment Form Used?

1. Review your department’s current controls, processes and practices.
2. Assess your practice at least once a year. Departments must initiate routine assessments—the process must be cyclical and self-initiating.
3. Incorporate self-monitoring into existing process reviews or quality initiative activities. Whenever possible, involve staff in discussions on ways to safeguard patient information.
4. Conduct assessments as if you are a patient or outside entity scrutinizing your methods for securing patient information. Note: Some measures are best monitored without advance notice to staff (e.g., reports, charts or faxes left on counters).
5. Keep documentation of your assessments and resulting process improvements in file.

For questions contact the Office of Corporate Compliance at (909) 651-4200, extension 14200 or ComplianceAssessment@llu.edu.