CTR066203_Exhibit_G.pdf
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- Attached to
- Master Agreement AZ|CTR066203
- Contract number
- CTR066203
- Issued by
- Arizona
About this file
This document is a Data Breach Report Form from Exhibit G of Amendment 3 to Contract CTR066203, issued by the Arizona Department of Economic Security (ADES). The form provides a structured template for organizations to report data breaches, with strict instructions to protect the personally identifiable information (PII) of survivors or clients. The form requires detailed reporting within 24 hours of a data breach incident, including submission to the contract and program specialists.
The document focuses on capturing critical information about a potential data breach, including the date of the incident, the organization's response, and preventative measures for future protection. While no specific details are filled in on this template, the form mandates comprehensive reporting without revealing personal identifying information. Organizations are required to describe the incident, explain their response and notification process to affected individuals, and outline strategies to prevent future data breaches. ADES will review the submitted form and follow up within one business day to confirm receipt and determine appropriate next steps.
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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
CTR066203 - 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 .