PCI DSS Proposal Request Form

Organization name

Contact Name

Title

Address

City

State

Zipcode

Phone

System Information

Type of organization

# of sites to be assessed

# of employees

# of servers

# of end systems

Business Information

Time-frame for project to begin

Has assessment been budgeted?

Are you a Merchant, Issuer, or Service Provider?

What is the merchant level?

Have you identified and documented all locations and flows of cardholder data, as well as identified and documented all systems that are connected to or, if compromised, couldimpact the CDE (for example, authentication servers)?

Date of previous ROC or SAQ (whichever is applicable) in the past?

Have PCI DSS policies been reviewed, updated in past 12 months?

Regulations organization must comply with?

HIPAA
HITECH Breach
Meaningful Use
PCI DSS
HITRUST
Other

Scope of proposal?

Does your organization have a Business Associate Agreement?

Date project must be completed by?

Comments

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