Form Pi 1 - Ssa Data Incident Report Page 2
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2STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
4. If the employee/contractor who was in possession of the data or to whom the data was assigned is not the
person making the report (as listed in #1), information about this employee/contractor:
NAME:
POSITION:
STATE:
COUNTY AGENCY:
PHONE NUMBERS:
WORK:
CELL:
HOME/OTHER:
E-MAIL ADDRESS:
5.
Circumstances of the loss:
a. When was it lost/stolen? ________________________________________________________________________
b. Brief description of how the loss/theft occurred:______________________________________________________
c. When was it reported to SSA management official (date and time)?______________________________________
6. Have any other SSA components been contacted? If so, who? (Include deputy commissioner level, agency
level, regional/associate level component names)
_________________________________________________________________________________________________
_________________________________________________________________________________________________
7. Which reports have been filed? (include FPS, local police, and SSA reports)
Report Filed
Federal Protective Service
Yes
No Report Number_____________________
Local Police
Yes
No Report Number_____________________
OIG
Yes
No Report Number_____________________
SSA-3114 (Incident Alert)
Yes
No
SSA-342 (Report of Survey)
Yes
No
Security Assessments and Funded Enhancements (SAFE)
Yes
No
Other (describe) ________________________________________________________________________________
_________________________________________________________________________________________________
8. Other pertinent information (include actions under way, as well as any contacts with other agencies, law
enforcement or the press):
9. Describe how the incident or potential incident was discovered, including the date and time of discovery:
PI 1 (6/15) (SSA DATA INCIDENT REPORT) REQUIRED FORM - NO SUBSTITUTE PERMITTED
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