CTR066202_Exhibit_G.pdf
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- Attached to
- Master Agreement AZ|CTR066202
- Contract number
- CTR066202
- Issued by
- Arizona
About this file
This document is a Data Breach Report Form (Exhibit G) from Amendment 4 of Contract CTR066202, issued by the Arizona Department of Economic Security (ADES). The form is designed to be completed by an agency experiencing a data breach, with specific instructions for reporting the incident within 24 hours to the contract and program specialists. The form emphasizes strict confidentiality, instructing the reporting agency to avoid disclosing any Personally Identifying Information (PII) about survivors or clients.
The document provides a structured template for documenting data breach details, including fields for the date of the breach, date of ADES notification, a description of the incident, the organization's response, and a plan for preventing future breaches. The form requires the reporting agency to submit this document along with their current Data Breach Policy. ADES commits to responding within one business day of receiving the report to confirm receipt and discuss next steps. The form is part of a comprehensive data protection protocol aimed at maintaining the privacy and security of sensitive client information.
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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
CTR066202 - 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 .