This questionnaire is designed to gather information from individuals who have experienced a breach of privacy. The responses will help in understanding the nature and impact of the breach, and in determining the appropriate legal or remedial actions. This questionnaire is also useful in relation to complaints made to the ACNC and the Office of Fair Trading in Queensland (and its equivalent in other States of Australia).

The information you provide will only be used for these two purposes and only if you give your permission at the end of this questionnaire. The information you provide will only be viewed by Samson’s legal team (solicitors) and essential personnel of the Samson Rising organization, each of whom has signed a confidentiality agreement. No personal and sensitive information you give us will be displayed on the Samson Rising website or the Street Car forum unless we ask for and receive your specific permission to do so.

A breach of privacy can occur even if someone you gave your private information to, did not say whether they would or would not disclose your information to others. In most situations, your informed consent is required before they can disclose your private information to others. A breach of your privacy can still occur even if your name is not mentioned to others. As long as there’s a reasonable chance you could be identified by the release of the information, a privacy breach has occurred.

NB: If you don’t want to disclose the details of the privacy breach at this time, please indicate if the privacy breach involved your personal information, your sensitive information, or both.

Information about you or someone's opinion about you, including: Your name, Your address, and Your phone numbers, Date of birth, Medical records, Employment details, Financial details, Photographs, Opinions you may have.

Information about you or someone's opinion about you, including; your racial or ethnic origin, political opinions, religious beliefs or affiliations, philosophical beliefs, sexual orientation or practices, criminal record, or health information about you.

Sometimes physical proof of privacy breaches can be hard to find. Please tell us if you think you can get a signed statement from someone else to support important parts of your report. Supporting statements can be a good source of evidence that can really help.

This questionnaire is intended to assist in the preliminary assessment of a privacy breach and complaints to the ACNC, and Office of Fair Trading in Queensland (or its equivalent in other states). It does not constitute legal advice.