CTR066195_Exhibit_G.pdf
PDF 102 KB Posted
- Attached to
- Master Agreement AZ|CTR066195
- Contract number
- CTR066195
- Issued by
- Arizona
About this file
This document is a Data Breach Report Form (Exhibit G) from the Arizona Department of Economic Security (ADES), attached to Contract CTR066195, Amendment 3. The form is designed 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 to ADES, a description of the incident, the organization's response, and prevention strategies for future incidents.
The document provides a standardized template for reporting data security incidents, with specific procedural requirements. Organizations must submit the form within 24 hours of a data breach, along with their current Data Breach Policy, to their Contract Specialist and Program Specialist. ADES commits to responding within one business day of receiving the report to confirm receipt and discuss next steps. The form emphasizes the importance of maintaining confidentiality and protecting the identity of affected individuals throughout the reporting process.
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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
CTR066195 - Amendment 3
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 .