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Create an Incident Response Policy

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The Information System Incident Response Team has been created to provide direction and oversight of all activities directly related to intrusion of information technology equipment, telecommunication services, software network availability of the Healthcare IT infrastructure.

The purpose of this policy is to establish a protocol to guide a response to a computer incident or event impacting Healthcare computer equipment, data or networks.

This policy applies to employees, contractors, consultants, temporary employees, and other workers at Healthcare, including all personnel affiliated with third parties.
It applies to all equipment that is owned or leased by Healthcare.

Incident Reporting
All computer security incidents, including suspicious events, shall be reported immediately either orally or via e-mail to the department IT manager and/or department supervisor by the employee who witnessed or identified the breach.
Escalation
The department IT manager and/or department supervisor needs to determine the criticality of the incident. The department IT manager and/or department supervisor will refer to their IT emergency contact list for both management personnel and incident response members to be contacted. If the incident is something that will have serious impact, the Chief Information Officer of Healthcare will be notified and briefed on the incident. The Information Security Incident Team Manager will log all communications including:
a) The name of the caller.
b) Time of the call.
c) Contact information about the caller.
The CIO or his/her designee will determine if other agencies, departments, or personnel need to become involved in the reporting and resolution of the incident.
Containment:
Any system, network, or security administrator who observes an intruder on the Healthcare network or system shall take appropriate action to terminate the intruder’s access. An intruder can mean a hacker, botnet, malware, etc. Affected systems, such as those infected with malicious code or systems accessed by an intruder shall be isolated from the network until the extent of the damage can be assessed. Any discovered vulnerabilities in the network or system will be rectified by appropriate means as soon as possible.
Restoration
The extent of damage must be determined and course of action planned and communicated to the appropriate parties. Any need for restoration of system configurations, applications or data shall be made following eradication of the incident from clean backups.
Information Dissemination
Any public release of information concerning a computer security incident shall be coordinated through the office of the Healthcare CIO.
The CIO and/or his/her designee shall manage the dissemination of incident information to other participants, such as law enforcement or other incident response agencies and are responsible for posting of information that could affect the public, such as web page defacement or situations that disrupt systems or applications.
Ongoing Reporting
After the initial oral or e-mail report is filed, and if the incident has been determined to be a significant event (such as multiple workstations effected, root compromise, data breach, etc.), subsequent reports shall be provided to the CIO and appropriate managers. Incidents such as individual workstations infected with malware are considered minor events and need not be followed up with a written report.
The incident reports shall be submitted within 24 hours of the incident. An agency/department may be required to provide reports sooner in accordance with more stringent regulations such as HIPAA requirements. If this is the case, the more stringent requirements are to be met as required.
General reports to the Information Security Incident Team Manager and CIO shall contain the following:
• Point of contact
• Affected systems and locations
• System description, including hardware, operating system, and application software
• Type of information processed, such as HIPAA related information
• Incident description
• Incident resolution status
• Damage assessment, including any data loss or corruption
• Organizations contacted
• Corrective actions taken
• Lessons learned
Review:
After the initial reporting and/or notification, the IT manager, department managers, The Information Security Incident Team Manager and CIO shall review and reassess the level of impact that the incident created. Review response and update policies—plan and take preventative steps so the intrusion can't happen again.

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