Data Breach Response Policy

1.0 Purpose

The purpose of the policy is to establish the goals and the vision for the breach response process. This policy will clearly define to whom it applies and under what circumstances, and it will include the definition of a breach, staff roles and responsibilities, standards and metrics (e.g., to enable prioritization of the incidents), as well as reporting, remediation, and feedback mechanisms. The policy shall be well publicized and made easily available to all personnel whose duties involve data privacy and security protection.

iSenseLabs Information Security's intentions for publishing a Data Breach Response Policy are to focus significant attention on data security and data security breaches and how Consentmo’s established culture of openness, trust and integrity should respond to such activity. Consentmo Information Security is committed to protecting Consentmo's employees, partners and the company from illegal or damaging actions by individuals, either knowingly or unknowingly.

1.1 Background

This policy mandates that any individual who suspects that a theft, breach or exposure of Consentmo Protected data or Consentmo Sensitive data has occurred must immediately provide a description of what occurred via e-mail to security@constentmo.com, or through the use of the help desk reporting web page . This e-mail address, and web page are monitored by the Information Security Administrator. This team will investigate all reported thefts, data breaches and exposures to confirm if a theft, breach or exposure has occurred. If a theft, breach or exposure has occurred, the Information Security Administrator will follow the appropriate procedure in place.

2.0 Scope

This policy applies to all whom collect, access, maintain, distribute, process, protect, store, use, transmit, dispose of, or otherwise handle personally identifiable information or Protected Health Information (PHI) of Consentmo members. Any agreements with vendors will contain language similar that protects the fund.

3.0 Policy Confirmed theft, data breach or exposure of Consentmo Protected data or Consentmo Sensitive data

As soon as a theft, data breach or exposure containing Consentmo Protected data or Consentmo Sensitive data is identified, 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
Communications
The affected unit or department that uses the involved system or output or whose data may have been breached or exposed
Additional departments based on the data type involved, Additional individuals as deemed necessary by the Executive Director

3.1 Confirmed theft, breach or exposure of Consentmo data

The Executive Director will be notified of the theft, breach or exposure. IT, along with the designated forensic team, will analyze the breach or exposure to determine the root cause.

Work with Forensic Investigators

As provided by Consentmo cyber insurance, the insurer will need to provide access to forensic investigators and experts that will determine how the breach or exposure occurred; the types of data involved; the number of internal/external individuals and/or organizations impacted; and analyze the breach or exposure to determine the root cause.

Develop a communication plan.

Work with Consentmo 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.

Incident Response Process Overview

Below is the structured 6-step process followed in this document as defined by the SANS Institute in their Incident Handler’s Handbook. The six steps outlined are:

Preparation—review and codify an organizational security policy, perform a risk assessment, identify sensitive assets, define which are critical security incidents the team should focus on, and build a Computer Security Incident Response Team (CSIRT).

Identification—monitor IT systems and detect deviations from normal operations and see if they represent actual security incidents. When an incident is discovered, collect additional evidence, establish its type and severity, and document everything.

Containment—perform short-term containment, for example by isolating the network segment that is under attack. Then focus on long-term containment, which involves temporary fixes to allow systems to be used in production, while rebuilding clean systems.

Eradication—remove malware from all affected systems, identify the root cause of the attack, and take action to prevent similar attacks in the future.

Recovery—bring affected production systems back online carefully, to prevent additional attacks. Test, verify and monitor affected systems to ensure they are back to normal activity.

Lessons learned—no later than two weeks from the end of the incident, perform a retrospective of the incident. Prepare complete documentation of the incident, investigate the incident further, understand what was done to contain it and whether anything in the incident response process could be improved.

3.2 Ownership and Responsibilities

Roles & Responsibilities:

Sponsors - Sponsors are those members of the Consentmo community that have primary responsibility for maintaining any particular information resource. Sponsors may be designated by any Consentmo Executive in connection with their administrative responsibilities, or by the actual sponsorship, collection, development, or storage of information.
Information Security Administrator is that member of the Consentmo community, designated by the Executive Director or the Director, Information Technology (IT) Infrastructure, who provides administrative support for the implementation, oversight and coordination of security procedures and systems with respect to specific information resources in consultation with the relevant Sponsors.
Users include virtually all members of the Consentmo community to the extent they have authorized access to information resources, and may include staff, trustees, contractors, consultants, interns, temporary employees and volunteers.
The Incident Response Team shall be chaired by Executive Management and shall include, but will not be limited to, the following departments or their representatives: IT-Infrastructure, IT-Application Security; Communications; Legal; Management; Financial Services, Member Services; Human Resources.

4.0 Enforcement

Any Consentmo personnel found in violation of this policy may be subject to disciplinary action, up to and including termination of employment. Any third party partner company found in violation may have their network connection terminated.

5.0 Definitions

Encryption or encrypted data - The most effective way to achieve data security. To read an encrypted file, you must have access to a secret key or password that enables you to decrypt it. Unencrypted data is called plain text;

Plain text - Unencrypted data.

Hacker - A slang term for a computer enthusiast, i.e., a person who enjoys learning programming languages and computer systems and can often be considered an expert on the subject(s).

Protected Health Information (PHI) - Under US law is any information about health status, provision of health care, or payment for 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 one person from another and can be used for de-anonymizing anonymous data can be considered.

Protected data - See PII and PHI

Information Resource - The data and information assets of an organization, department or unit.

Safeguards - Countermeasures, controls put in place to avoid, detect, counteract, or minimize security risks to 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 - Data that is encrypted or in plain text and contains PII or PHI data. See PII and PHI above.

Last updated: 04 April, 2023