Ds 5340-B - Dds Incident Response Reporting Form printable pdf download

Ds 5340-B - Dds Incident Response Reporting Form

State of California-Health and Human Services Agency

Department of Developmental Services

DDS Incident Response Reporting Form

DS 5340-B (New August 2016) (Electronic Version)

Entity Name:

B. Incident Information

1. Details of Incident:

a) Date incident occurred:

Unknown

b) Date incident detected:

Unknown

c) Incident location:

d) General description:

e) Media/Device type, if applicable:

Was the portable storage device encrypted?

Yes

If NO, explain:

f) Describe the costs associated with resolving this incident:

g) Total estimated cost of incident:

2. Incidents involving personally identifiable information

a) Was personally identifiable information involved?

Yes

(If No, go to Part C)

Type of personally identifiable information (Check all that apply)

Name

Health or Medical Information

Social Security Number

Financial Account Number

Driver's License/State ID Number

Other (Specify)

b) Is a privacy disclosure notice required?

Yes

c) If a Privacy Disclosure Notice is required, attach a sample of the notification.

d) Number of individuals affected:

e) Date notification(s) made:

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July 2016

Ds 5340-B - Dds Incident Response Reporting Form