CTR066193_Exhibit_G.pdf
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- Attached to
- Master Agreement AZ|CTR066193
- Contract number
- CTR066193
- Issued by
- Arizona
About this file
This document is a Data Breach Report Form from Exhibit G of Contract CTR066193, Amendment 4, issued by the Arizona Department of Economic Security (ADES). The form provides a standardized template for organizations to report data breaches involving sensitive information, with strict instructions to protect personally identifiable information (PII) of survivors or clients. The form requires detailed documentation of the breach, including the date of occurrence, notification timeline, incident description, organizational response, and future prevention strategies.
The form itself does not detail specific goods or services, but serves as a critical administrative mechanism for documenting and responding to potential data security incidents. It mandates that organizations submit the form within 24 hours of a data breach, along with their current Data Breach Policy, to designated contract and program specialists. ADES commits to responding within one business day of receiving the report to confirm receipt and outline next steps. The document emphasizes confidentiality, requiring organizations to use generic terms like "Survivor" or "client" to avoid revealing specific identifying details about affected individuals.
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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
CTR066193 - 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.”
Data Breach Report Form
File details come from the government source that posted it. Updated .