CTR066188_Exhibit_G.pdf
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- Attached to
- Master Agreement AZ|CTR066188
- Contract number
- CTR066188
- Issued by
- Arizona
About this file
This document is a Data Breach Report Form, Exhibit G, associated with Contract CTR066188 - Amendment 4 for the Arizona Department of Economic Security (ADES). The form is designed to provide a standardized method for reporting data breaches, with specific instructions emphasizing the protection of Personally Identifying Information (PII) and requiring submission within 24 hours of an incident.
The form itself is a template for documenting the details of a data breach, including the date of the breach, date of notification, a description of the incident, the organization's response, and planned preventative measures for future occurrences. It requires the reporting agency to fill out comprehensive information without revealing specific identifying details about any survivors or clients involved. ADES will review the submitted form and respond within one business day, providing guidance and confirmation of next steps in addressing the data breach.
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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
CTR066188 ‐ 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.”
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