Data Breach Reporting Form

Pursuant to Ark. Code Ann. § 4-110-105, if you are a business, state agency or health care provider that has experienced a data breach, you may provide notice of a data breach to the Arkansas Attorney General using this reporting form. Notifications provided to the Attorney General may be used by the Attorney General to investigate the data breach or any related incident or conduct. Read more about details on when notice to the Attorney General is required.

The Arkansas Personal Information Protection Act requires entities that collect personal information, such as businesses, state agencies, and health care providers, to use reasonable security procedures and practices to protect such information. Additionally, the law mandates that in the event such information is compromised, the entity must notify the affected individuals in a timely manner. Notification to individuals whose personal information has been compromised allows them to take steps to mitigate the potential misuse of their information.

Data Breach Reporting

Affected Business Entity Name
Affected Business Entity Address
Street Address Address Line 2 City State Zip
What product or service does the affected business provide?
Reporting Entity Name (if different than affected entity)
Relationship to Affected Business
Contact Person's Name
First Last
Contact Person's Title
Phone
Email
Date Breach Incident Began
MM slash DD slash YYYY
Date Breach Discovered
MM slash DD slash YYYY
Date Breach Contained
MM slash DD slash YYYY
Were Arkansas residents affected?
- No
- Yes
How many were affected?
Explanation of Personal Information Involved
What steps has the business entity taken to address the incident?

The following are examples of the type of information that you should provide:
Internal investigation
Forensic investigation
Notified law enforcement
Frozen compromised accounts
Amended administrative safeguards (such as company practices, policies or procedures)
Amended technical or physical safeguards
Deleted information
Other
Was notice provided to affected customers?
- No
- Yes
Provide the date(s) that notice was provided to customers.
Provide a sample copy of the notice letter.
Drop files here or

Max. file size: 120 MB.
Do you have supporting documents?
Drop files here or

Max. file size: 120 MB.

Data Breach Reporting Form

Data Breach Reporting

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