CTR066205__Exhibit_G.pdf
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- Attached to
- Master Agreement AZ|CTR066205
- Contract number
- CTR066205
- Issued by
- Arizona
About this file
This document is a Data Breach Report Form (Exhibit G) from Amendment 4 of contract CTR066205, issued by the Arizona Department of Economic Security (ADES). The form is designed to be completed by an agency or organization that has experienced a data breach, with specific instructions for reporting the incident to ADES within 24 hours. The form emphasizes strict confidentiality, requiring the reporting entity to omit any Personally Identifying Information (PII) about survivors or clients involved in the incident.
The document provides a structured template for reporting data breaches, including sections for documenting the date of the breach, date of ADES notification, a detailed incident description, the organization's response to the breach, notification of affected survivors/clients, and a plan for preventing future data breaches. The form is part of a contractual requirement that mandates prompt reporting and collaborative follow-up between the reporting organization and ADES. The final section is reserved for ADES to document their response and follow-up actions, ensuring a comprehensive and systematic approach to managing potential data security incidents.
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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
CTR066205 ‐ 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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