Section 1

Complete and submit within 72 hours of determination or notification.

Determined

☐ Finance Cabinet Secretary

☐ Auditor of Public Accounts (APA)

☐ Kentucky State Police (KSP)

☐ Attorney General (AG)

☐ Commissioner of Department of Library and Archives, if breach determined

☐ Chief Information Officer of Commonwealth Office of Technology

☐ Commissioner of Department of Local Government

☐ Commissioner of Kentucky Department of Education

☐ President of Council on Postsecondary Education

If Department of Local Government under KRS 61.931(1)(b) or (c) also contact:

If Public School District listed in KRS 61.931(1)(d) also contact:

If Educational entity listed under KRS 61.931(1)(e) also contact:

Agency Name:

Agency Contact:

Agency Contact Email:

Agency Contact Phone Number:

Date of Notification to Agencies: ___ Time of Notification: ___ Date Breach Determined: ___

Complete this portion after the conclusion of the investigation regarding whether the Security Breach has resulted in or is likely to result in the misuse of personal information. Provide notice to agencies within 48 hours of completing investigation.

Personal Information Breached: ☐ Yes ☐ No

If Yes, Explain:

Total Number of Individuals Impacted: Date Individuals Notified:

Type of Notices Sent Out (select all that apply and provide explanations):

Web Posting:

Email:

Local or Regional Media:

Telephone:

☐ Letter:

□ Other: