Test Page Security Breach

Security Breach Form

North Carolina Security Breach Reporting Form Pursuant to the Identity Theft Protection Act of 2005

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Name of the Company or Government Agency Owning or Licensing Information affected by the Entity Experiencing Breach * Required
Entity Type * Required
Address Line 1
Address Line 2
City
State
Zip Code
Telephone
Fax
Email
Date the Security Breach was Discovered * Required
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Is this notice a supplement to a previously filed security breach?
Breach Type * Required
Estimated Number of affected Individuals * Required
Estimated Number of NC residents affected * Required
Name of company or government agency maintaining or possessing information that was the subject of the Security Breach, if the agency that experienced the Security Breach is not the same entity as the agency reporting the Security Breach (pursuant to N.C.G.S. 75-65(b))
Describe the circumstances surrounding the Security Breach * Required
Information Taken * Required
Please use the control key to select multiple options.
Breached Information Format
Regarding Information breached, if electronic, was the information protected in some manner?
If yes, please describe the security measures protecting the information:
Describe any measures taken to prevent a similar Security Breach from occurring in the future * Required
Date affected NC residents were/will be notified: * Required
YYYY dash MM dash DD
Describe the circumstances surrounding the delay in notifying affected NC residents pursuant to NCGS 75-65 (a) and (c).
How NC residents were/will be notified? (Pursuant to N.C.G.S. 75-65(e)) * Required
Please use the control key to select multiple options.
Notice include email, statewide media and website posting?
Please note if the business demonstrates that the cost of providing notice would exceed two hundred fifty thousand dollars ($250,000) or that the affected class of subject persons to be notified exceeds 500,000, or if the business does not have sufficient contact information or consent to satisfy subdivisions (1), (2), (3) of this subsection, for only those affected persons without sufficient contact information or consent, or if the business is unable to identify particular affected persons, for only those unidentifiable affected persons. Substitute notice shall consist of all the following:
Email notice when the business has an electronic mail address for the subject person
Conspicuous posting of the notice on the website page of the business, if one is maintained
Notification to major statewide media
Please attach a copy of the notice if in written form or a copy of any scripted notice if in telephonic form. * Required
Drop files here or

Accepted file types: doc, docx, jpg, png, pdf, gif, xlsx, txt, Max. file size: 2 MB, Max. files: 2.
Maximum file size - 2 mega bytes.
Additional File Upload
Accepted file types: doc, docx, jpg, png, pdf, gif, xlsx, Max. file size: 8 MB.
Maximum file size - 8 mega bytes.
Additional file upload
Accepted file types: doc, docx, jpg, png, pdf, gif, xlsx, Max. file size: 8 MB.
Maximum file size - 8 mega bytes.
Affiliation with entity experiencing breach: * Required
Organization Name
Prefix
First Name * Required
Middle Name
Last Name * Required
Suffix
Title
Address Line 1
Address Line 2
City
State
Zip Code
Telephone * Required
Fax
Email Address * Required
Signature * Required
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Date
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