Data Breach Response Policy


This policy establishes how we will respond in the event of a data breach, and also outlines an action plan that will be used to investigate potential breaches and to mitigate damage if a breach occurs. This policy is in place to both minimize potential damages that could result from a data breach and to ensure that parties affected by a data breach are properly informed of how to protect themselves.


This policy applies to all incidents where a breach of customer or employee’s personal identifying information is suspected or confirmed.


Personal Identifying Information (PII) – Information that that can be used to distinguish or trace an individual’s identity. PII includes, but is not limited to, any of the following:

  • Social Security numbers
  • Credit Card information
  • Tax identification information numbers (Social Security Numbers, business identification numbers, employer identification numbers)
  • Payroll Information
  • Insurance Information
  • Other personal information of a customer, employee or contractor (dates of birth, addresses, phone numbers, maiden names, names, customer numbers)

Breach – Any situation where PII is accessed by someone other than an authorized user, for anything other than an authorized purpose.

Policy Guidelines

A breach or a suspected breach of PII must be immediately investigated. Since all PII is of a highly confidential nature, only personnel necessary for the data breach investigation will be informed of the breach. The following information must be reported to appropriate management personnel:

  • When (date and time) did the breach happen?
  • How did the breach happen?
  • What types of PII were obtained? (Detailed as possible)
  • How many customers were affected?

Management will then make a record of events and people involved, as well as any discoveries made over the course of the investigation and determine whether or not a breach has occurred.

Perform a Risk Assessment

Once a breach has been verified and contained, perform a risk assessment that rates the:

  • Sensitivity of the PII Lost
  • Amount of PII Lost and Number of Individuals Affected
  • Likelihood PII is Usable or May Cause Harm
  • Likelihood the PII was intentionally targeted (increases chances for fraudulent use)
  • Strength and Effectiveness of Security Technologies Protecting PII
  • Ability to Mitigate the Risk of Harm

All information collected during the risk assessment must then be compiled into one report and analyzed. The Risk Assessment must then be provided to appropriate personnel in charge of data breach response management.

Notifying Affected Parties

Responsibility to notify is based both on the number of individuals affected and the nature of the PII that was accessed. Any information found in the initial risk assessment will be turned over to the legal counsel of who will review the situation to determine if, and to what extent, notification is required. Notification should occur in a manner that ensures the affected individuals will receive actual notice of the incident. Notification will be made in a timely manner, but not so soon so as to unnecessarily compound the initial incident with incomplete facts or to make identity theft more likely through the notice.

In the case that notification must be made:

  • Only those that are legally required to be notified will be informed of the breach. Notifying a broad base when it is not required could cause unnecessary concern in those who have not been affected.
  • A physical copy will always be mailed to the affected parties no matter what other notification methods are used (e.g. phone or email).
  • The notification letter will include:
  • A brief description of the incident. The nature of the breach and the approximate date it occurred.
  • A description of the type(s) of PII that were involved in the breach. (The general types of PII, not an individual’s specific information)
  • Explanation of what is being done to investigate the breach, mitigate its negative effects and prevent future incidences.
  • Steps the individual can take to mitigate any potential side effects from the breach.
  • Contact information for a representative who can answer additional questions.

Mitigating Risks

Based off the findings of the risk assessment, a plan will be developed to mitigate risk involved with the breach. The exact course of action will be based on the type of PII that was involved in the data breach. The course of action will aim to minimize the effect of the initial breach and to prevent similar breaches from taking place.

ACA Compliance Services, Inc. will also provide steps to mitigate risks that can be taken by affected individuals. The steps provided to affected individuals will depend on the nature of the data breach. If the breach has created a high risk for fraudulent use of financial information, customers may be advised:

  • Monitor their financial accounts and immediately report any suspicious or fraudulent activity.
  • Contact the three major credit bureaus and place an initial fraud alert on the credit reports. This can be extremely helpful in situations where PII that can be used to open new accounts, such as Social Security Numbers, as been taken.
  • Avoid attempts from criminals that may see the breach as an opportunity to pose as employees in an attempt to deceive affected individuals into divulging personal information.
  • File a report with local police or in the community where the breach took place.
  • Complete a Federal Trade Commission Threat Affidavit, available at . This form will allow the affected individual to notify their creditors that their identity has been compromised and will minimize their liability for fraudulent use of their identity.