CTR066207_Exhibit_G.pdf
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- Attached to
- Master Agreement AZ|CTR066207
- Contract number
- CTR066207
- Issued by
- Arizona
About this file
This document is a Data Breach Report Form from Exhibit G, associated with Contract CTR066207 - Amendment 5 for the Arizona Department of Economic Security (ADES). The form is designed to be completed by an agency that has experienced a data breach, with specific instructions to submit the form within 24 hours of an incident to the contract and program specialists.
The form provides a structured template for reporting data breaches, with sections for documenting the agency name, date of breach, incident details, organizational response, and future prevention strategies. Critically, the form emphasizes protecting Personally Identifying Information (PII) and instructs users to avoid disclosing specific details that could identify individuals, instead using generic terms like "Survivor" or "client". The document requires the reporting organization to describe the breach comprehensively without revealing personal information, outline their response to the breach, and explain measures to prevent future incidents. ADES will review the submission and respond within one business day.
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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
CTR066207 - 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 .