The University of Illinois at Chicago. Health Science Colleges

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1 POLICY NUMBER: 9 INFORMATION SYSTEMS SECURITY POLICY NAME: SECURITY INCIDENT RESPONSE AND REPORTING Responsible Office HSC IT Group Effective Date 10/31/2011 Responsible Official William Chamberlin Last Revision 10/31/2011 Policy Sections 9.0 Purpose Policy Delegation Policy Common Incident Response and Reporting System Reporting and Responding to IT Security Incidents Documentation of Security Incidents User Password Compromise Procedures Required by or Referencing this Policy Forms Required by or Referencing this Policy Guidelines Required by or Referencing this Policy Standards Required by or Referencing this Policy Violations Policy Authority Responsibility for Process and Procedure Compliance Monitor Special Situations/Exceptions Contacts Revision History Purpose The have adopted this policy to provide a framework for the response and reporting of security incidents within the. This POLICY NUMBER: 9 Security Incident Response and Reporting Version 3.0 Page 1 of 8

2 Policy covers common incident response and reporting, responding to security incidents, and mitigation of known security incidents. This Policy is a statement of the minimum requirements, responsibilities and accepted behaviors required to establish and maintain a secure technology environment within the Health Sciences Colleges as well as achieving the stated security objectives. This information security Policy emphasizes the Health Sciences Colleges commitment to strong information security and requires adherence to this Policy by any individuals who utilize the information technology resources of the Health Sciences Colleges and the University resources they depend upon. The University s Combined Covered Entity 1, including the Health Sciences Colleges, is committed to securing and protecting High Risk data 2 including electronic Protected Health Information (ephi), 3 in accordance with widely accepted information systems security best practices and standards including those established by the International Organization for Standardization and the International Electrotechnical Commission (IEC); the ISO/IEC series of Information Systems Security standards; the National Institute of Standards and Technology (NIST) Information Security Standards and Guides; and the Standards for Security and Privacy of individually identifiable health information established by the Department of Health and Human Services under the Health Insurance Portability and Accountability Act of 1996 (HIPAA) subject to later modification by the Health Information Technology for Economic and Clinical Health (HITECH) Act of 2009 as part of the American Recovery and Reinvestment Act (ARRA) of , 2, 3 See Covered Entity, High Risk data, and electronic Protected Health Information (ephi) definitions in HSC Policy Definitions POLICY NUMBER: 9 Security Incident Response and Reporting Version 3.0 Page 2 of 8

3 9.1 Policy Delegation An individual Health Science College may delegate the duties herein to departments or other units within the individual Health Science College, or to other campus units or external vendors. If a duty is delegated, then a Service Agreement defining what is delegated, to whom it is delegated, and the duties still required of the individual Health Science College will be identified. 9.2 Policy Common Incident Response and Reporting System The have created an Incident Response and Reporting System to report, mitigate, and document security incidents and violations, which is defined in Procedure 9.The may delegate the Recipient role for Incident Reports and the Responder role for Incident Response to Units within the Colleges, or to other campus units, or to external vendors. If either role is delegated, a Service Agreement defining what is delegated, to whom it is delegated, and the reporting or response still required of or to the colleges will be identified Reporting and Responding to IT Security Incidents 4 All incidents, threats, or violations that may affect the confidentiality, integrity, or availability of High Risk data must be reported and responded to by following HSC Procedure 9, Security Incident Response and Reporting, and by using the following guidelines: a. Incident Reporters will notify their CISO of security incidents involving significant network or system-related attacks or unauthorized access attempts. b. The CISO will investigate and recommend updates or fixes in response to security incidents and concerns. Incident Response will be coordinated by the Incident 4 See IT Security Incident definition in HSC Policy Definitions POLICY NUMBER: 9 Security Incident Response and Reporting Version 3.0 Page 3 of 8

4 Responder with the CISO and be based upon the best practices guidelines of the NIST Computer Security Incident Handling Guide SP c. The CISO is responsible for initiating dialogue between the College and the University s Combined Covered Entity Security and Privacy Officers to discuss and resolve HIPAA security and/or privacy related issues. d. The CISO will ensure that all initial contact from outside authorities regarding any security incident as defined in section a above will initially be directly to the ACCC Security Office Documentation of Security Incidents The CISO will document all security-related incidents and their outcomes. Each Health Science College will develop and implement disaster recovery response and recovery and reporting procedures for significant failures, outages, or data losses potentially resulting from reasonable and foreseeable Security Incidents that involve High Risk data including ephi User Password Compromise If a user believes their user identification s password has been compromised, they must report that security incident to the entity that issued the account and the College Information Security Officer or delegate. POLICY NUMBER: 9 Security Incident Response and Reporting Version 3.0 Page 4 of 8

5 9.3 Procedures Required by or Referencing this Policy This: 9.2.2b References: NIST Computer Security Incident Handling Guide SP HSC Policy 3, Contingency Plan Controls 9.9 HSC Policy b 9.4 Forms Required by or Referencing this Policy None 9.5 Guidelines Required by or Referencing this Policy None 9.6 Standards Required by or Referencing this Policy None 9.7 Violation Any individual found to have violated this policy may be subject to disciplinary action up to and including termination of employment, regardless of tenure status. 9.8 Policy Authority Information Technology Group 9.9 Responsibility for Process and Procedure By Policy b, the Individual Health Science College and any organizational unit thereunder reporting a security incident Compliance Monitor The Individual Health Science College POLICY NUMBER: 9 Security Incident Response and Reporting Version 3.0 Page 5 of 8

6 9.11 Special Situations/Exceptions Any exceptions to this policy must be approved by the Information Technology Group and reported to the College Information Security Officer Any personally-owned devices, such as PDAs, phones, wireless devices, or other electronic transmitters that have been determined to contribute to an Incident, may be subject to seizure and retention by a College until the Incident has been remediated, unless the custody of these devices is required as evidence in a court case. By using these devices within a College network for business purposes, individuals are subject to the College s policies restricting their use Contacts Subject Contact Phone Applied Health Sciences Mike Kirda Dr. Annette Valenta Dentistry Jay Dean Medicine Andre Pavkovic Interpretation of Policy Nursing Ursula Brozek Bala Ramaraju Pharmacy Philip J. Reiter Public Health Faith Davis Dr. Sylvia Furner La Don Reed POLICY NUMBER: 9 Security Incident Response and Reporting Version 3.0 Page 6 of 8

7 9.13 Revision History 12/10/2007 Initial draft composed by College of Medicine: Ian Huggins, Robert McAuley, Andre Pavkovic 3/25/2009 Reviewed and Approved by HSC IT Group College of Medicine: Robert McAuley, Andre Pavkovic, Ian Huggins. College of Applied Health Sciences: Mike Kirda, Dr. Annette Valenta. College of Dentistry: Jay Dean. College of Nursing: Bala Ramaraju. College of Pharmacy: Philip Reiter. School of Public Health: La Don Reed (with input by Academic Computing and Communications Center and University of Illinois Medical Center) 3/03/2010 Updated 1.12 Contacts, completed first annual review of HSC Policies 7/07/ /2010 through 6/2011 HSC IT Group Review of Policies - Edited by Judith Grobe Sachs; Group s following consensus revisions summarized by Ian Huggins 7/21/2011 Updated language by Mike Kirda, Judith Grobe Sachs, Ian Huggins, and Doug McCarthy 8/19/2011 Updated language, added numbering and automatic table of contents, added cross-references by Doug McCarthy. 10/31/2011 HSC IT Group approval of 10/2010 through 8/2011 Policy POLICY NUMBER: 9 Security Incident Response and Reporting Version 3.0 Page 7 of 8

8 revisions, this completes the second annual review of the Policies. POLICY NUMBER: 9 Security Incident Response and Reporting Version 3.0 Page 8 of 8

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