CTR066210_Exhibit_G.pdf
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- Attached to
- Master Agreement AZ|CTR066210
- Contract number
- CTR066210
- Issued by
- Arizona
About this file
This document is a Data Breach Report Form (Exhibit G) for Amendment 3 of Contract CTR066210, issued by the Arizona Department of Economic Security (ADES). The form is designed to be completed by an organization in the event of a data breach, requiring detailed reporting without disclosing personally identifiable information (PII) of survivors or clients.
The form provides a structured template for documenting critical information about a data breach, including the date of the incident, date of notification to ADES, a description of the incident, the organization's response, how affected survivors or clients were notified, and preventative measures for future data breaches. The instructions specify that the form must be submitted within 24 hours of the incident, accompanied by the organization's current Data Breach Policy, and that ADES will contact the organization within one business day to confirm receipt and discuss 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
CTR066210 ‐ 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.”
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