Ds 5340-B - Dds Incident Response Reporting Form Page 2

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)

C. Corrective Actions Planned/Taken to Prevent Future Occurrences:

1. Estimated cost of corrective actions:

2. Date corrective actions will be fully implemented:

D. Signatures:

Printed Name of Information

Signature of Information

(Date)

Security Officer

Printed Name of Privacy Officer

Signature of Privacy Officer

(Date)

(Required if privacy incident occurred whether or not notices were sent)

Printed Name of Director or

Signature of Director or Designee

(Date)

Designee

E-Mail this completed Incident Report to the following address:

ISO@dds.ca.gov

Page 2 of 2

July 2016

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