Report a Data Breach

Data Breach Notification Form

About the Reporting Entity

Supplemental Notice(Required)

Please select "Yes" if this is a supplemental notice.

Name of Entity(Required)

Street Address(Required)

City(Required)

State(Required)

Postal Code(Required)

Country

Website

All 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

For more information on these categories, click here

If Other Entity(Required)

Please provide a brief explanation

Submitted By(Required)

First Last

Title(Required)

Firm

If different from Entity name

Your Phone(Required)

Your Email(Required)

Relationship to Entity(Required)

Provide your relationship to the Entity that was breached

Street Address(Required)

City(Required)

State(Required)

Postal Code(Required)

Country

About the Breach

Type 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

Number of Persons Affected

Colorado residents only(Required)

Please enter the total number of Colorado residents impacted

Total 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

Date Breach Ended(Required)

Please enter the approximate date the breach ended

Date Incident Discovered(Required)

Date Your Investigation Began(Required)

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).

Date Colorado Residents Notified(Required)

Additional Date(s) Colorado Residents Notified

If applicable, please enter the additional notification dates to Colorado Residents

Additional Date(s) Colorado Residents Notified

If applicable, please enter the additional notification dates to Colorado Residents

Do you plan to provide notice to more Colorado residents in the future?(Required)

Would 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

Date Breach Ended

Please enter the approximate date the breach ended

Date Incident Discovered

Date Your Investigation Began

Date of Determination

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).

Date Colorado Residents Notified

Additional Date(s) Colorado Residents Notified

If applicable, please enter the additional notification dates to Colorado Residents

Additional Date(s) Colorado Residents Notified

If applicable, please enter the additional notification dates to Colorado Residents

Do you plan to provide notice to more Colorado residents in the future?

Would you like to report a 3rd incident relating to this notification?

Yes

Date Breach Started

Please enter the approximate date on which the breach began

Date Breach Ended

Please enter the approximate date the breach ended

Date Incident Discovered

Date Your Investigation Began

Date of Determination

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).

Date Colorado Residents Notified

Additional Date(s) Colorado Residents Notified

If applicable, please enter the additional notification dates to Colorado Residents

Additional Date(s) Colorado Residents Notified

If applicable, please enter the additional notification dates to Colorado Residents

Do you plan to provide notice to more Colorado residents in the future?

Form of Notice to Colorado Residents(Required)

Please select all that apply

Electronic

Written

Telephonic

Substitute Notice

Please identify the reason you provided substitute notice:(Required)

Upload Example Notice

Max. file size: 128 MB.

Type of Breach

Was the Data Encrypted?(Required)

Type of Security Breach(Required)

Please select all that apply

Location of Breached Information(Required)

Please select all that apply

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 breach

Please 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).

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.

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Comments

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