Form Pi 1 - Ssa Data Incident Report
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2STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
SSA DATA INCIDENT REPORT
Worksheet for Reporting Loss or Potential Loss of Personally Identifiable Information (PII)
1.
Information about the individual making the report:
NAME:
POSITION:
STATE:
COUNTY AGENCY:
PHONE NUMBERS:
WORK:
CELL:
HOME/OTHER:
E-MAIL ADDRESS:
CHECK ONE OF THE FOLLOWING:
Management Official
Security Officer
Non-Management
2.
Information about the data that was lost/stolen:
Describe what was lost or stolen (e.g., case file, MBR data):
Which element(s) of PII did the data contain?
Name
Bank Account Info
SSN
Medical/Health Information
Date of Birth
Benefit Payment Info
Place of Birth
Mother’s Maiden Name
Address
Other (describe):___________________________________________________________
3. How was the data physically stored, packaged and/or contained?
Paper or
Electronic? (check one and continue below):
If Electronic, what type of device?
Laptop
Tablet
Backup Tape
Smart Phone
Workstation
Server
CD/DVD
Smart Phone Phone #______________
Hard Drive
Floppy Disk
USB Drive
Other (describe):_____________________________________________________________________________
Additional Questions if Electronic:
a. Was the device encrypted?
Yes
No
Not Sure
b. Was the device password protected?
Yes
No
Not Sure
c. If a laptop or tablet, was a VPN SmartCard lost?
Yes
No
Not Sure
d. If laptop, powerstate when lost?
Off
Sleep
Hibernate
Not Sure
Cardholder’s Name:______________________________________________________________________________
Cardholder’s SSA logon PIN:_______________________________________________________________________
Hardware Make/Model:____________________________________________________________________________
Hardware Serial Number:__________________________________________________________________________
Additional Questions if Paper:
a. Was the information in a locked briefcase?
Yes
No
Not Sure
b. Was the information in a locked cabinet or drawer?
Yes
No
Not Sure
c. Was the information in a locked vehicle trunk?
Yes
No
Not Sure
d. Was the information redacted?
Yes
No
Not Sure
e. Other circumstances:___________________________________________________________________________
PI 1 (6/15) (SSA DATA INCIDENT REPORT) REQUIRED FORM - NO SUBSTITUTE PERMITTED
PAGE 1 OF 2
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