RC-AI-03 AI Risk Assesment form
Document 2: AI Risk Assessment Form
REEVES COUNTY
AI SYSTEM RISK ASSESSMENT FORM
General Information
Project Name:
Department:
Project Manager:
Vendor:
Date Submitted:
SECTION 1 – SYSTEM DESCRIPTION
Describe the AI system:
Purpose of the system:
SECTION 2 – DATA REVIEW
Will the system process:
|
Data Type |
Yes |
No |
|
Public Data |
□ |
□ |
|
Employee Data |
□ |
□ |
|
Financial Data |
□ |
□ |
|
Criminal Justice Data |
□ |
□ |
|
Medical Data |
□ |
□ |
|
Sensitive Personal Information |
□ |
□ |
If yes, describe safeguards:
SECTION 3 – DECISION IMPACT
Does the AI system influence:
|
Function |
Yes |
No |
|
Hiring |
□ |
□ |
|
Discipline |
□ |
□ |
|
Permitting |
□ |
□ |
|
Procurement |
□ |
□ |
|
Public Benefits |
□ |
□ |
|
Law Enforcement |
□ |
□ |
If yes, explain human oversight controls:
SECTION 4 – SECURITY REVIEW
Vendor Security Documentation Provided?
□ Yes
□ No
Data Encrypted?
□ Yes
□ No
Multi-Factor Authentication Supported?
□ Yes
□ No
SOC 2 Report Available?
□ Yes
□ No
SECTION 5 – BIAS ASSESSMENT
Could the system impact individuals differently based on:
- Race
- Gender
- Age
- Disability
- National Origin
□ Yes
□ No
If yes, explain mitigation measures:
SECTION 6 – LEGAL REVIEW
County Attorney Review Required?
□ Yes
□ No
Review Completed?
□ Yes
□ No
Date:
SECTION 7 – OVERALL RISK RATING
□ Low Risk
□ Moderate Risk
□ High Risk
Comments:
APPROVALS
Department Head:
IT Director:
County Attorney:
County Judge/Designee: