CTR066206_Exhibit_G.pdf
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- Attached to
- Master Agreement AZ|CTR066206
- Contract number
- CTR066206
- Issued by
- Arizona
About this file
This document is a Data Breach Report Form from Exhibit G of Contract CTR066206 - Amendment 5, issued by the Arizona Department of Economic Security (ADES). The form provides a structured template for organizations to report data breaches involving sensitive information, with strict instructions to protect personally identifying information (PII) of survivors or clients. The form requires detailed documentation of the breach, including the date of occurrence, notification timelines, incident description, organizational response, and future prevention strategies.
The form is specifically designed for comprehensive yet confidential reporting of data security incidents, with mandatory submission within 24 hours of an event to designated contract and program specialists. Key requirements include submitting the completed form along with the organization's current Data Breach Policy, using generic terms like "Survivor" or "client" to maintain anonymity, and awaiting a response from ADES within one business day. The document emphasizes a structured approach to data breach management, focusing on transparency, swift communication, and protective measures without compromising individual privacy.
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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
CTR066206 - Amendment 5
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 .