VERMONT STATE SECURITY BREACH PRELIMINARY REPORTING FORM

Pursuant to the Vermont Security Breach Notice Act
(9 V.S.A. §§ 2430, 2435)

Name and address of Entity that owns or licenses the computerized data that was subject to the breach

Name

Address

City/Town

State/Province

ZIP/Postal Code

Submitted By

Name

Title

Dated

Firm Name (if other then entity)

Telephone

Relationship to Entity whose information was compromised

Dates

Breach Occured

Breach Discovered

Please note that the discovery date is NOT the date than an investigation is completed, it is the earliest date than an entity became aware of, or had a reasonable belief of, unathorized activity.

Description of Breach

(select all that apply)

Loss or theft of device or media (e.g., computer, hard drive, thumb drive, CD, tape)

Internal system breach

Insider wrongdoing

External system breach (e.g., hacking)

Inadvertent disclosure

Other…

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