CTR066186__Exhibit_G.pdf

Agency Name:

Date of data breach:

Date ADES was notified about the data breach:

Describe Incident: (Please provide as much detail as possible, without disclsoing any of the Survivor's personally identifying information) Organization’s response to the data breach, including how affected survivors/clients were notified:

Describe how the organization will prevent data breaches in the future:

(ADES will fill out) ADES Response to organization and date:

EXHIBIT G

CTR066186 ‐ Amendment 4

Arizona Department of Economic Security

DATA BREACH REPORT FORM

Instructions: Please submit this form along with your current Data Breach Policy within 24 hours of the incident to your Contract Specialist and Program Specialist. Once ADES receives this form, they will contact you within one (1) business day for confirmation that it was received and next steps, as appropriate. For questions about this form, please emai your Contract Specialist and Program Specialist.

DO NOT include any of a Survivor’s Personally Identifying Information (PII). PII includes but is not limited to a Survivor’s first or last name, address, email, phone number, and any other information that would serve to identify them. If the situation involves a Survivor, you can use the term “Survivor” or “client.”