CTR066187__Exhibit_G.pdf
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- Attached to
- Master Agreement AZ|CTR066187
- Contract number
- CTR066187
- Issued by
- Arizona
About this file
This document is a Data Breach Report Form (Exhibit G) associated with Contract CTR066187, Amendment 5, for the Arizona Department of Economic Security (ADES). The form provides a template for organizations to report data breaches, with specific instructions emphasizing the protection of Personally Identifying Information (PII) and requiring submission within 24 hours of an incident.
The form is designed to capture critical details about a potential data breach, including the date of occurrence, date of notification to ADES, a detailed description of the incident, the organization's response, how affected survivors or clients were notified, and proposed preventative measures for future data breaches. The document includes empty fields for the reporting organization to complete, with a section reserved for ADES to provide its response and follow-up actions. The form explicitly instructs users to avoid disclosing any personally identifying information about survivors or clients when describing the incident.
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Text version
Agency Name:
Date of data breach:
Date ADES was notified about the data breach:
Describe Incident: (Please provide as much detail as possible, without disclosing 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
CTR066187 ‐ Amendment 5
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.”
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