Data Breach Response Policy
**1.0 Purpose Purpose**
TheThis purposepolicy ofestablishes the policy is to establish the goalsframework and the visionobjectives for the organization's data breach response process. ThisIt policy will clearly define to whom it applies and under what circumstances, and it will includedefines the definitionscope of aapplicability, breach,outlines staffprocedures for suspected or confirmed breaches, clarifies roles and responsibilities, sets standards for incident prioritization, and metrics (e.g., to enable prioritization of the incidents), as well asmandates reporting, remediation, and feedback mechanisms. The purpose is to ensure a coordinated, effective, and timely response to protect the organization's data, personnel, and stakeholders. This policy shallmust be welleffectively publicizedcommunicated and madereadily easily availableaccessible to all personnel whoseinvolved duties involvein data privacy and security protection.
The
organization<ORGANIZATIONis NAME>committed Informationto Security's intentions for publishingmaintaining a Dataculture Breachof Responseopenness, Policytrust, areand integrity. This includes a proactive approach to focus significant attention on data security and dataa securitystructured breaches and how <ORGANIZATION NAME>’s established culture of openness, trust and integrity should respondresponse to suchpotential activity.breaches. <ORGANIZATION NAME> Information Security is committed to protecting <ORGANIZATION NAME>'s employees, partners and the company from illegal or damaging actions by individuals, either knowingly or unknowingly.
Background
This policy mandatesaims thatto anyprotect the organization, its employees, partners, and associated individuals from harm resulting from unauthorized data access or disclosure, whether intentional or unintentional.
**2.0 Background**
Any individual who suspects that a theft, breachbreach, or unauthorized exposure of <ORGANIZATIONthe NAME>organization's Protected dataData or <ORGANIZATION NAME> Sensitive dataData may have occurred has occurredan mustimmediate immediately provide a description of what occurred via e-mailobligation to Helpdesk@<ORGANIZATIONreport NAME>.org,the byincident. callingReports 555-1212,should ordescribe the circumstances and be submitted promptly through the usedesignated ofinternal thechannels help(e.g., deskIT Help Desk email, dedicated phone line, or internal reporting web page at http://<ORGANIZATION NAME>portal). ThisThese e-mailreporting address, phone number, and web pagechannels are actively monitored by the <ORGANIZATION NAME>’sdesignated Information Security Administrator.personnel Thisor team responsible for initiating investigations. All reports will investigatebe all reported thefts, data breaches and exposuresinvestigated to confirmdetermine if a theft,data breach or exposure has occurred. IfConfirmed aincidents theft,will breach or exposure has occurred,trigger the Informationestablished SecurityIncident AdministratorResponse will follow the appropriate procedure in place.Procedure.
**3.0 Scope**
2.0 Scope
This policy applies to all whomemployees, contractors, vendors, and partners who collect, access, maintain, distribute, process, protect, store, use, transmit, dispose of, or otherwise handle personally identifiable informationsensitive or protected information, including Personally Identifiable Information (PII) and Protected Health Information (PHI), on behalf of <ORGANIZATIONthe NAME>organization. members. Any agreementsAgreements with third-party vendors willmust containinclude languageprovisions similarrequiring thatadherence protectsto thecomparable fund.data protection and breach notification standards.
**4.0 Policy: Incident Response Protocol**
3.0**4.1 PolicyIncident ConfirmedConfirmation and Initial Response**
Upon confirmation of a theft, data breach, or exposure involving Protected or Sensitive Data, immediate steps will be taken to contain the incident, including isolating affected systems and revoking access where necessary to prevent further unauthorized activity.
**4.2 Incident Response Team Activation**
The designated Executive Leader (e.g., Executive Director, Chief Information Security Officer) will activate and chair an Incident Response Team (IRT) to manage the breach or exposure event. The core IRT will be composed of <ORGANIZATIONrepresentatives NAME>from Protectedrelevant datadepartments, or <ORGANIZATION NAME> Sensitive dataincluding:
*
ITAsInfrastructure
* soonIT asApplications a/ theft,Information dataSecurity
* breachLegal orCounsel
* exposureCommunications containing/ <ORGANIZATIONPublic NAME>Relations
* ProtectedFinance data(if or <ORGANIZATION NAME> Sensitivefinancial data is identified,impacted)
* the process of removing all access to that resource will begin.
The Executive Director will chair an incident response team to handle the breach or exposure.
The team will include members from:
• IT Infrastructure
• IT Applications
• Finance (if applicable)
• Legal
• Communications
• MemberMember/Customer Services (if Membermember/customer data is affected)
*
• Human Resources
*
•The Thebusiness unit(s) directly affected unit or departmentresponsible that usesfor the involvedcompromised system or output or whose data may have been breached or exposed
• Additional departments based on the data type involved,system/data.
* Additional individualsmembers as deemed necessary by the ExecutiveIRT Director
based
onConfirmedthe theft,nature breachand or exposure of <ORGANIZATION NAME> data
The Executive Director will be notifiedscope of the theft,incident.
**4.3 orInvestigation exposure.and IT,Analysis**
The withIRT, potentially supported by internal IT and designated external forensic specialists (often coordinated through cyber insurance providers), will conduct a thorough investigation. The objectives are to:
* Determine the designatedroot forensiccause team, will analyzeof the breach or exposureexposure.
* to determineIdentify the root cause.
Work with Forensic Investigators
As provided by <ORGANIZATION NAME> cyber insurance, the insurer will need to provide access to forensic investigators and experts that will determine how the breach or exposure occurred; thespecific types of data involved;involved.
* Ascertain the extent of the impact, including the number of internal/external individuals and/or organizations impacted;potentially affected.
* Assess the scope and analyzeseverity of the breach or exposure to determine the root cause. incident.
**4.4 Communication Strategy**
DevelopThe IRT, in collaboration with Legal, Communications, and Human Resources departments, will develop and execute a strategic communication plan. This plan will address necessary notifications to:
* Internal personnel
* Regulatory bodies (as required by law)
* Affected individuals
* The public, if deemed necessary.
Work with <ORGANIZATION NAME> communications, legal and human resource departments to decide how to communicate the breach to: a) internal employees, b) the public, and c) those directly affected.
3.2**5.0 Ownership and ResponsibilitiesResponsibilities**
Roles* &**Data Responsibilities:
Individuals
or•departments Sponsors - Sponsors are those members of the <ORGANIZATION NAME> community that havewith primary responsibility for maintainingoverseeing any particularspecific information resource.resources. Sponsors mayare betypically designated bybased anyon <ORGANIZATIONadministrative NAME>roles Executiveor their function in connectioncollecting, with their administrative responsibilities,developing, or bymanaging thedata.
* actual sponsorship, collection, development, or storage of information.
• **Information Security AdministratorAdministrator/Team:** isDesignated thatpersonnel member of the <ORGANIZATION NAME> community, designated by the Executive Director or the Director, Information Technology (IT) Infrastructure, who provides administrative supportresponsible for the administrative implementation, oversightoversight, and coordination of security procedures and systemssystems, with respect to specific information resourcesacting in consultation with the relevantData Sponsors.
*
•**Users:** Users include virtually allAll members of the <ORGANIZATION NAME>organization community to(including thestaff, extentcontractors, theyconsultants, haveetc.) with authorized access to information resources,resources. Users are responsible for adhering to security policies and mayreporting includesuspected staff,incidents.
* trustees, contractors, consultants, interns, temporary employees and volunteers.
• The **Incident Response Team shall(IRT):** be chairedChaired by Executive ManagementManagement, andthis shallcross-functional include,team butis willresponsible notfor be limited to,managing the followingresponse departmentsto orconfirmed theirdata representatives:breaches IT-Infrastructure,as IT-Applicationoutlined Security;in Communications;section Legal; Management; Financial Services, Member Services; Human Resources.4.2.
**6.0 Enforcement**
4.0 Enforcement
Any < ORGANIZATION NAME > personnel found in violationViolations of this policy by organizational personnel may beresult subject toin disciplinary action, up to and including termination of employment.employment, Anysubject thirdto applicable laws and internal procedures. Violations by third-party partner company found in violationpartners may havelead theirto remediation actions, including termination of contracts or network connection terminated. access.
**7.0 Definitions**
5.0* Definitions**Breach:**
Encryptionunauthorized acquisition, access, use, or encrypteddisclosure of Protected Data or Sensitive Data that compromises its security or privacy.
* **Encryption:** The process of converting data –(plain Thetext) most effective way to achieve data security. To read an encrypted file, you must have access tointo a secretcoded format (ciphertext) requiring a specific key or password thatfor enablesdecryption, you to decrypt it. Unencryptedenhancing data issecurity.
* called**Information plainResource:** text;
Plain text – Unencrypted data.
Hacker – A slang term for a computer enthusiast, i.e., a person who enjoys learning programming languagesdata and computerinformation systemsassets andmanaged can often be considered an expert onby the subject(s).
Protected Health Information (PHI) - Under US law is any information about health status, provision of health care,organization or paymentits forunits.
* health care that is created or collected by a "Covered Entity" (or a Business Associate of a Covered Entity), and can be linked to a specific individual.
**Personally Identifiable Information (PII) - Any data that could potentially identify a specific individual.:** Any information that can be used to distinguish oneor persontrace froman anotherindividual's andidentity, either alone or when combined with other personal or identifying information.
* **Protected Health Information (PHI):** As defined under applicable laws (e.g., HIPAA in the US), information relating to health status, healthcare provision, or payment for healthcare that can be usedlinked forto de-anonymizinga anonymousspecific dataindividual.
* can be considered
**Protected dataData:** -A Seecollective term referring to PII andand/or PHI
Informationrequiring Resource - The data and information assets of an organization, department or unit.
Safeguards - Countermeasures, controls put in place to avoid, detect, counteract, or minimizespecific security risksmeasures.
* to**Plain physical property, information, computer systems, or other assets. Safeguards help to reduce the risk of damage or loss by stopping, deterring, or slowing down an attack against an asset.
Sensitive data -Text:** Data that is encryptednot orencrypted.
* in**Safeguards:** plainTechnical, textadministrative, and containsphysical PIIcontrols orimplemented PHIto data.protect information Seeresources PIIfrom threats and PHIminimize above.security risks.
* **Sensitive Data:** Data classified by the organization as requiring protection due to its confidential nature, including but not limited to Protected Data.