NCDOJ

Security Breach Reporting Form

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), or (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 persons
Conspicuous posting of the notice on the Web site page of the business, if one is maintained
Notification to major statewide media

* Name of the Company or Government Agency owning or licensing information affected by the entity experiencing breach:


* Entity Type:

Address:

Apt/Suite/Building:

City:

State:

Zip Code:

Telephone:	() -Second partThird part

Fax:	() -Second partThird part

Email:

* Date the Security Breach was discovered:	Date and time

* Breach Type:

*Is this notice a supplement to a previously filed security breach?:

* Estimated number of affected individuals:

* Estimated number of NC residents affected:

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:

Information Taken:	Account Number Access Number CC/DC Driver License Medical Information Passport SSN

* Regarding information breached, if electronic, was the information protected in some manner:	Yes No N/A - it was a paper breach

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:

* Date affected NC residents were/will be notified:	Date and time

Describe the circumstances surrounding the delay in notifying affected NC residents pursuant to N.C.G.S. 75-65 (a) and (c):

If the delay was pursuant to a request from law enforcement pursuant to N.C.G.S. 75-65(c), please attach or mail the written request or the contemporaneous memorandum.
How NC residents were/will be notified?: (pursuant to N.C.G.S. 75-65(e))	written notice electronic notice (email) telephone notice substitute notice
	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), or (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 persons Conspicuous posting of the notice on the Web site 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.