Data Breach Notification Form About the Reporting EntitySupplemental Notice(Required)Please select "Yes" if this is a supplemental notice. YesNoName of Entity(Required) Street Address(Required) City(Required) State(Required)ALAKAZARCACOCTDCDEFLGAHIIDILINIAKSKYLAMEMDMAMIMNMSMOMTNENVNHNJNMNYNCNDOHOKORPARISCSDTNTXUTVTVAWAWVWIWYPacificPostal Code(Required) Country WebsiteAll website entries must start with one of the following prefixes: http:// or https://. If the website is unknown or entry errors occur, please leave blank. Entity Telephone Number(Required)Entity Type(Required)Please select an option AdministrationBusiness/EmploymentCharitable/NonprofitConstructionEducationalEntertainmentFinancial servicesFood ServicesGovernment - ColoradoGovernment - Outside of ColoradoHealthcareInformation and TechnologyInsuranceLegal ServicesManufacturingOil and GasOtherReal Estate and Rental and LeasingRetail/MerchantTransportationTravel AccommodationUtility For more information on these categories, click here If Other Entity(Required)Please provide a brief explanation Submitted By(Required) First Last Title(Required) FirmIf different from Entity name Your Phone(Required)Your Email(Required) Relationship to Entity(Required)Provide your relationship to the Entity that was breachedIn House CounselLaw firm or Outside attorneyOwnerEmployeeOtherStreet Address(Required) City(Required) State(Required)ALAKAZARCACOCTDCDEFLGAHIIDILINIAKSKYLAMEMDMAMIMNMSMOMTNENVNHNJNMNYNCNDOHOKORPARISCSDTNTXUTVTVAWAWVWIWYPacificPostal Code(Required) Country About the BreachType of Personal Information(Required)Please select all that may apply Account number or credit or debit card number in combination with any required security code, access code, or password that would permit access to that account Biometric data Driver’s license number or identification card number Health insurance identification number Medical information Social security number Student, military, or passport identification number Username or e-mail address, in combination with a password or security questions and answers, that would permit access to an online account Select All Number of Persons AffectedColorado residents only(Required)Please enter the total number of Colorado residents impactedTotal number of people impacted(Required)Please enter the total number of people impacted, including Colorado residents Dates relating to the data breach(es)Date Breach Started(Required)Please enter the approximate date on which the breach began Month Day Year Date Breach Ended(Required)Please enter the approximate date the breach ended Month Day Year Date Incident Discovered(Required) Month Day Year Date Your Investigation Began(Required) Month Day Year Date of Determination(Required)Please enter the date of determination regarding misuse or reasonable likelihood of misuse of personal information. See C.R.S. 6-1-716(2)(a). Month Day Year Date Colorado Residents Notified(Required) Month Day Year Additional Date(s) Colorado Residents NotifiedIf applicable, please enter the additional notification dates to Colorado Residents Month Day Year Additional Date(s) Colorado Residents NotifiedIf applicable, please enter the additional notification dates to Colorado Residents Month Day Year Do you plan to provide notice to more Colorado residents in the future?(Required)YesNoWould you like to report an additional incident relating to this notification? Yes Date Breach Started(Required)Please enter the approximate date on which the breach began Month Day Year Date Breach EndedPlease enter the approximate date the breach ended Month Day Year Date Incident Discovered Month Day Year Date Your Investigation Began Month Day Year Date of DeterminationPlease enter the date of determination regarding misuse or reasonable likelihood of misuse of personal information. See C.R.S. 6-1-716(2)(a). Month Day Year Date Colorado Residents Notified Month Day Year Additional Date(s) Colorado Residents NotifiedIf applicable, please enter the additional notification dates to Colorado Residents Month Day Year Additional Date(s) Colorado Residents NotifiedIf applicable, please enter the additional notification dates to Colorado Residents Month Day Year Do you plan to provide notice to more Colorado residents in the future?YesNoWould you like to report a 3rd incident relating to this notification? Yes Date Breach StartedPlease enter the approximate date on which the breach began Month Day Year Date Breach EndedPlease enter the approximate date the breach ended Month Day Year Date Incident Discovered Month Day Year Date Your Investigation Began Month Day Year Date of DeterminationPlease enter the date of determination regarding misuse or reasonable likelihood of misuse of personal information. See C.R.S. 6-1-716(2)(a). Month Day Year Date Colorado Residents Notified Month Day Year Additional Date(s) Colorado Residents NotifiedIf applicable, please enter the additional notification dates to Colorado Residents Month Day Year Additional Date(s) Colorado Residents NotifiedIf applicable, please enter the additional notification dates to Colorado Residents Month Day Year Do you plan to provide notice to more Colorado residents in the future?YesNo Form of Notice to Colorado Residents(Required)Please select all that apply Electronic Written Telephonic Substitute Notice Select AllPlease identify the reason you provided substitute notice:(Required)The cost of providing individual notice exceeds two hundred fifty thousand dollarsThe affected class of persons to be notified exceeds two hundred fifty thousand Colorado residentsYou do not have sufficient contact information to provide individual noticeUpload Example NoticeMax. file size: 1 GB. Type of BreachWas the Data Encrypted?(Required)YesNoPartiallyType of Security Breach(Required)Please select all that apply Denial of Service Error Hacking Insider Misuse Lost or Stolen Equipment Malware: Ransomware Malware: Other Other Social Engineering: Other Social Engineering: Phishing Website: Other Website: Point of Sale Location of Breached Information(Required)Please select all that apply Email Kiosk/Terminal Media: payment card Media: portable storage Media: other Other Server: cloud server Server: network Server: other User Device: desktop or laptop computer User Device: mobile User Device: other Web Application If Other Type of Security Breach(Required)Please provide a brief explanation If Other Location of Breached Information(Required)Please provide a brief explanation Brief Description of the Security Breach(Required)Please provide a brief description of the breachPlease provide any additional information you wish to include If you would like a copy of your report, please click the print button below (this function will not be available after you submit your report). Print Your Report Colorado Open Records The contact information, date range of the reported breach, types of affected personal information, and examples of consumer notices may be a public record and disclosed to third parties outside the Office of the Colorado Attorney General. All other information submitted in the form are confidential investigatory materials and intelligence information. CAPTCHAEmailThis field is for validation purposes and should be left unchanged.
