developing an information technology risk management program training for dhhs information security...

Developing an Information Technology Risk

Management ProgramTraining for DHHS Information Security Officials and Backup Security Officials

What this training covers . . What Risk Management means What NIST says you should do What ISO 17799 says you should do What COBIT says you should do What Microsoft says you should do What HIPAA says you should do What NC ITS says you should do What DHHS says you should do What you should do and when to do it

“Take calculated risks. That is quite different from being rash.” General George S. Patton

“Only those who risk going too far can possibly find out how far they can go” T.S. Elliot

“Of course you have to go out on a limb sometimes; that’s where the fruit is” Unknown

Risk

Information Security

the protection of data against unauthorized

access or modification

What is “Risk”? Risk is the net mission impact considering both the

likelihood that a particular threat-source will exercise (accidentally trigger or intentionally exploit) a particular information system vulnerability, and the resulting impact on the organization if this should occur (NIST)

Risk is the probability of a vulnerability being exploited in the current environment, leading to a degree of loss of confidentiality, integrity, or availability, of an asset. (Microsoft)

What is Risk Management? The total process of identifying, controlling,

and minimizing information system related risks to a level commensurate with the value of the assets protected

The goal of a risk management program is to protect the organization and its ability to perform its mission from IT-related risk

Risk Management is the Keystone of Information Security

Golden and Silver Rules of RM

All risk is owned!Risk that is not assigned

is owned by the organization’s Director

Why are we doing this? Why do we do risk management? Why does a car have brakes?

An organization that can take advantage of opportunities (and the inherent risks) will outlast an organization which cannot

Reactive Risk Management

1) Protect human life and people’s safety

2) Contain the damage

3) Assess the damage

4) Determine the cause of the damage

5) Repair the damage

6) Review response, and update policies

Owners

Controls

Threat Sources

Vulnerabilities

Risk

Assets

Threats

to reduce

leading to

that increase

that may bereduced by

that may possess

to

impose

give riseto

wish to abuse and/or may damage

may be aware of

thatexploit

wish to minimize

value

to

Proactive Risk Management

Owners

Controls

Threat Sources

Vulnerabilities

Risk

Assets

Threats


What Assets are we Protecting? Servers Desktop Computers Laptops and PDAs Switches and Routers Application software Development Tools Source Code VPN Access Backup Tapes

Email Data Integrity All Files on the Server Consumer Information Network Infrastructure DHCP Web Site Availability Reputation Employee Morale

Owners

Controls

Threat Sources

Vulnerabilities

Risk

Assets

Threats


Protecting From What Threats?

Human Threats – Carelessness, Shoulder Surfing, User Abuse, Sabotage, Arson, Data Entry Errors, Intentional and Unintentional Procedure Violations

Technical Threats – Takeover of authorized session, Intrusion, Keystroke Eavesdropping, System Failure, Saturation of Resources

Environmental Threats – Fire, Earthquake, Hurricane, Tornado, Cable Cuts, Power Fluctuation, Hazardous Material Accident, Overheating

Owners

Controls

Threat Sources

Vulnerabilities

Risk

Assets

Threats


Threats to What Vulnerabilities? Unlocked doors Unlocked windows Misconfigured systems Missing patches Antivirus out-of-date Poorly written apps Vendor backdoors Spyware

Software Configuration Systems not monitored Unnecessary protocols Poorly defined procedures Stolen credentials Poor password protection Poor Disaster Recovery Violations not reported

Owners

Controls

Threat Sources

Vulnerabilities

Risk

Assets

Threats


Vulnerabilities Protected by What Security Controls?

Controls Physical Technical Administrative

Preventive Key-card access to enter area

System & Network Monitoring

Security Awareness Training for staff

Detective Seals on archive file cabinets

Admin message on 3 incorrect logins

Audit of employee exit procedures

Deterrent Closed-circuit camera monitor

Account lockout after 3 attempts

Data owner approval of rights

Corrective Physical Isolation of servers

Firewall changes from past events

Arranging for day time cleaning

Recovery Electronic records recreate physical

Netware’s file “Salvage” option

Contact police after security breach

Owners

Controls

Threat Sources

Vulnerabilities

Risk

Assets

Threats

to reduce

leading to

that increase

that may bereduced by

that may possess

to

impose

give riseto

wish to abuse and/or may damage

may be aware of

thatexploit

wish to minimize

value

to


Two Approaches to Risk Assessment

Value your assets Determine the SLE (total amount lost from a single

occurrence of the risk) Single Loss Expectancy

Determine the ARO (number of times you expect the risk to occur during one year) Annual Rate of Occurrence

Determine the ALE (amount you will lose in one year if the risk is not mitigated) Annual Loss Expectancy

Determine the ROSI (ALE before control) – (ALE after control) – (annual cost of control) = ROSI Return On Security Investment

1) Quantitative Risk Assessment

Two Approaches to Risk Assessment

Estimate relative values Determine what threats each asset may be facing Determine what vulnerabilities those threats might

exploit in the future Determine controls which will mitigate the risks,

and the approximate cost of each control Management performs a cost-benefit analysis on

the results

2) Qualitative Risk Assessment

Comparing the Two Approaches – the BenefitsQuantitative Qualitative

1) Risks and assets are prioritized by financial values

2) Results facilitate management of risk by Return on Security Investment

3) Results expressed in terms management understands ($)

4) Accuracy tends to increase over time

1) Enables visibility and understanding of risk ranking

2) Easier to reach consensus

3) Not necessary to quantify threat frequency or determine financial value of assets

4) Easier to involve people who are not experts on security or computers

Comparing the Two Approaches – the DrawbacksQuantitative Qualitative

1) Impact values assigned to risks are based on subjective opinion

2) Very time-consuming

3) Calculations can be very complex

4) Results are presented only in monetary terms, and can be difficult for non-technical people to interpret

5) Process requires expertise

1) Insufficient differentiation between important risks

2) Difficult to justify investing in control implementation when there is no basis for a cost-benefit analysis

3) Results are dependent on the quality of the Risk Management Team that is created

Effective Risk Management

Threats

Potential Damage

Attempts toaccess privateinformation

Fraud

Malicious attacks

Pranks

Natural disasters

Sabotage

User error

:Public’s Loss of confidence

Critical operations halted

Sensitive information disclosed

Services and benefits interrupted

Failure to meet contractual obligations

Assets lostIntegrity of data and reports compromised

Know what to do now?

Who Wants to Help You?

NIST - The National Institute of Standards and Technology

NIST is a non-regulatory Federal agency with the mission of developing and promoting measurement, standards and technology to enhance productivity and improve quality of life

They invent – an atomic clock; a cement-like substance that promotes bone regrowth

They develop - software for the 170 VA hospitals; complex computational models

The set standards – weights and measures, cholesterol testing, and . . . Information Security

Pertinent NIST Publications SP 800-12 An Introduction to Computer

Security: The NIST Handbook SP 800-18 Guide for Developing Security

Plans for Information Technology Systems SP 800-26 Security Self-Assessment

Guide for Information Technology Systems SP 800-30 Risk Management Guide for

Information Technology Systems

The goal of Risk Management is to protect the organization and its ability to perform its mission

The focus is the mission; not IT assets Risk Management, therefore, is an

essential management function of the organization

NIST Says

It’s a Management Function

NIST Says

Risk Management has Three Parts Risk Assessment - Determining where risks

lie, and how big they are Risk Mitigation - Prioritizing, evaluating, and

implementing appropriate risk-reducing controls

Evaluation and Assessment – Since Risk Management is continuous and evolving, the past year’s Risk Management efforts should be assessed and evaluated prior to beginning the cycle again

Risk Management Process

Risk Assessment

Risk Mitigation

RM Evaluation

National Institute of Standards and Technology SP 800-30

The Ten Steps of Risk Assessment

1) System Characterization2) Threat Identification3) Vulnerability Identification4) Control Analysis5) Identify Threat-source/Vulnerability Pairs6) Likelihood Determination7) Impact Analysis 8) Risk Determination9) Control Recommendations10) Results Documentation


Risk Assessment

Risk Mitigation

Risk Mitigation Risk Mitigation is the process of identifying

areas of risk that are unacceptable; and estimating countermeasures, costs and resources to be implemented as a measure to reduce the level of risk

Determining “appropriate risk-reducing controls” is a job for your Risk Management Committee

What is “Acceptable” Risk? Setting your agency’s “risk appetite” is up to

your Director and Senior Management Because elimination of all risk is impossible,

we must use the least-cost approach and implement the most appropriate controls to decrease mission risk to an acceptable level, with minimal adverse impact on the organization’s resources and mission

Risk Mitigation Options Assume the Risk – Accept the risk and

continue operating (how big is your appetite?) Avoid the Risk – Stop running the program

or sharing the data Transfer the Risk – Use options to

compensate for the loss, such as insurance Lessen the Risk – Implement controls that

lessen the impact or lower the likelihood

Risk Mitigation Methodology1) Prioritize based on risk levels presented

2) Evaluate recommended control options

3) Conduct a cost-benefit analysis

4) Select additional controls, as necessary

5) Assign responsibility

6) Develop an action plan, if necessary

7) Implement the selected controls

Cost-Benefit Analysis If control reduces risk more than needed, see

if a less expensive alternative exists If control would cost more than the risk

reduction provided, then find something else If control does not reduce risk sufficiently,

look for more controls or a different control If control provides enough risk reduction and

is cost-effective, then use it

Residual Risk The risk remaining after the implementation

of new or enhanced controls is the residual risk

If the residual risk has not been reduced to an acceptable level, the risk management cycle must be repeated to identify a way of lowering the residual risk to an acceptable level

Understand that no IT system can be risk-free


Risk Assessment

Risk Mitigation

RM Evaluation

Evaluation and Assessment People, systems, and networks change,

so risk management must be ongoing Federal agencies must conduct risk

management at least every three years Stay flexible to allow changes when

warranted

NIST Says

Good Risk Management Depends Upon

1) Senior management’s commitment2) Support of the IT Team3) Competence of the Risk Management

Committee4) Cooperation and education of the users5) Ongoing assessment of IT-related

mission risks

ISO - International Organization of Standardization

In the late 1990s, the British Standard Institute (BSI) developed a program to accredit auditing firms, called “BS 7799”

When demand grew quickly for an information security standard, the ISO (International Organization for Standardization) adapted 7799 and released Part 1 in 2000 as “ISO 17799”

ISO 17799 defines a set of recommended information security management practices

On-line Purchases of ISO 177999 % 35 % 18% 9 % 6 % Others 9%

ISO 17799 – A Set of Recommendations ISO does not expect you to apply every piece

of the standard Instead ISO suggests that you consider each

recommendation as you try to improve your information security program

If a particular recommendation helps you address an important security need, then accept it – otherwise, ignore it

ISO 17799 Says “First, Understand”Perfect security may be achievable only for networkless servers located in rooms without doors in stone buildings without people on high ground with no earth faults in areas with very little rain

10 Key Contexts of ISO 17799

Access control

Asset classificationand control

Security policy

Organizational security

Personnel security

Physical and environmental

security Communications and operationsmanagement

Systems development & maintenance

Business continuity management

Compliance

Information

Integrity Confidentiality

Availability

ISO 17799 Deliverables

ISO 17799’s Information Security Management Process

1) Obtain Upper Management Support2) Define Security Perimeter3) Create Information Security Policy4) Create Info Security Management System5) Perform Risk Assessment6) Select and Implement Controls7) Document in Statement of Accountability8) Audit

ISO 17799 Risk Assessment Steps

1) Identify assets within the security perimeter

2) Identify threats to the assets

3) Identify vulnerabilities to the assets

4) Determine realistic probability

ISO’s

Probability of Event ScaleProbability

of EventFrequency Rating

Negligible Unlikely to Occur 0

Very Low 2 to 3 times every 5 years 1

Low Less than or equal to once per year 2

Medium Once every 6 months or less 3

High Once every month or less 4

Very High More than once every month 5

Extreme Once per day or more 6


1) Identify assets within the security perimeter2) Identify threats to the assets3) Identify vulnerabilities to the assets4) Determine realistic probability5) Calculate harm

ISO’s

Harm of Event ScaleHarm of Event Degree of Harm Rating

Insignificant Minimal to no impact 0

Minor No extra effort required to repair 1

Significant Tangible harm, extra effort required to repair 2

Damaging Significant expenditure of resources required; Damage to reputation and confidence

3

Serious Extended outage and/or loss of connectivity; Compromise of large amounts of data or services

4

Grave Permanent Shutdown; Complete compromise 5


1) Identify assets within the security perimeter

2) Identify threats to the assets

3) Identify vulnerabilities to the assets

4) Determine realistic probability

5) Calculate harm

6) Calculate risk (probability x harm)

ISO’s

Risk Scale

Risk Calculation(Probability times harm)

Rating

0 None

1 – 3 Low

4 – 7 Medium

8 – 14 High

15 – 19 Critical

20 – 30 Extreme

ISO 17799’s Information Security Management Process

1) Obtain Upper Management Support2) Define Security Perimeter3) Create Information Security Policy4) Create Info Security Management System5) Perform Risk Assessment6) Select and Implement Controls7) Document in Statement of Accountability8) Audit

COBIT – Control Objectives for Information and related Technology

Created by the Information Systems Audit and Control Association (ISACA) and the IT Governance Institute (ITGI)

The first edition was published in 1996, the second in 1998, the third in 2000, and the on-line edition became available in 2003

Recently found favor due to Enron scandal and the subsequent passage of the Sarbanes-Oxley Act

What COBIT Says You Should Do COBIT looks at information that is needed to

support business requirements and the associated IT resources and processes

COBIT has 34 high level objectives that cover 318 control objectives, categorized in four domains:

1) Planning and Organization2) Acquisition and Implementation3) Delivery and Support4) Monitor

High Level Objectives

COBIT – Planning and OrganizationP01 Define a Strategic IT Plan

P02 Define the Information Architecture

P03 Determine Technological Direction

P04 Define the IT Organization and Relationships

P05 Manage the IT Investment

P06 Communicate Management Aims and Direction

P07 Manage Human Resources

P08 Ensure Compliance with External Requirements

P09 Assess Risks

P10 Manage Projects

P11 Manage Quality


COBIT – Acquisition & Implementation

AI1 Identify Automated Solutions

AI2 Acquire and Maintain Application Software

AI3 Acquire and Maintain Technology Infrastructure

AI4 Develop and Maintain Procedures

AI5 Install and Accredit Systems

AI6 Manage Changes


COBIT – Delivery and SupportDS1 Define and Manage Service

Levels

DS2 Manage Third-Party Services

DS3 Manage Performance and Capacity

DS4 Ensure Continuous Service

DS5 Ensure Systems Security

DS6 Identify and Allocate Costs

DS7 Educate and Train Users

DS8 Assist and Advise Customers

DS9 Manage the Configuration

DS10 Manage Projects

DS11 Manage Data

DS12 Manage Facilities

DS13 Manage Operations


COBIT – Monitor

M1 Monitor the Processes

M2 Assess Internal Control Adequacy

M3 Obtain Independent Assurances

M4 Provide for Independent Audit

Microsoft Says . .

Successful Risk Management Requires:

Executive sponsorship A well-defined list of RM stakeholders Organizational maturity in terms of RM An atmosphere of open communication A spirit of teamwork A holistic view of the organization Security Risk Management Team authority

Microsoft Says . .

Risk Management Has Four Phases

1) Assessing Risk – Triage an entire list of security risks, identifying the most important

2) Conducting Decision Support – Potential control solutions are evaluated, and the best are recommended for mitigating top risks

3) Implementing Controls – Control solutions are put in place

4) Measuring Program Effectiveness – Checking to make sure that the controls are providing the expected protection

From Microsoft’s Security Risk Management Guide, Chapter 2

Microsoft Says . .

Assessing Risk Phase has Three Steps

1) Planning – Align your annual process with your budget; Specify your scope; Identify and pre-sell stakeholders; embrace subjectivity

2) Facilitated Data Gathering – Identify tangible and intangible assets, threats, vulnerabilities, existing controls, probable impact

3) Risk Prioritization – Determine probabilities, and combine impact with probability to produce a risk statement

Microsoft Says . .

Conducting Decision Support Phase

1) Determine functional requirements2) Identify combinations of controls

(Organizational, Operational, Technological)3) Compare proposed controls to functional

requirements4) Calculate the probable overall risk reduction to

the organization5) Estimate the cost of teach proposed control6) Select which controls to implement

Microsoft Says . .

Implementing Controls Phase

Good Network DesignSecure Wireless SegmentDisable LAN ServicesRemove User Rights Good Firewall SettingsLeast Privilege Necessary

Small attack surfaceFrequent Backups Encryption

Solid Building Structure

Microsoft Says . .

Measuring Program Effectiveness Phase

1) Ongoing – continues until next assessment phase

2) Should catch changes in the information systems environment, and in applications

3) Includes creating and maintaining a security risk scorecard that demonstrates the organization’s current risk profile

The Health Insurance Portability and Accountability Act of 1996

HIPAA Says Covered Entities Must

Ensure the confidentiality, integrity and availability of all protected health information the covered entity creates, receives, maintains or transmits

Protect against any reasonably anticipated threats or hazards to the security or integrity of such information

Final Rule, “Administrative Safeguards” – 45 CFR Part 164.306

HIPAA Security Specifications

1) Security Management Process – “Implement policies and procedures to prevent, detect, contain and correct security violations” Standard: (a)(1)(i)

2) Train workforce – “Implement a security awareness and training program for all members of its workforce (including management)” Standard: (a)(5)(i)


3) Information Systems Activity Review – “Implement procedures to regularly review records of information system activity, such as audit logs, access reports, and security incident tracking reports” Standard: (a)(1)(D)

4) Security Incidence Procedures – “Mitigate, to the extent practicable, harmful effects of security incidents that are known to the covered entity” Standard: (a)(6)(2)



5) Risk Analysis – A covered entity “must conduct an actual and thorough assessment of the potential risks and vulnerabilities of the confidentiality, integrity, and availability of electronic PHI held by the covered entity” Standard (a)(1)(2)(A)

6) Risk Management – A covered entity “must implement security measures sufficient to reduce risks and vulnerabilities to a reasonable and appropriate level” Standard (a)(1)(ii)(D)



. . And Why You Should Do It Civil Monetary Penalties for Non-Compliance

$100/person/violation, up to $25,000 per person per year per violation (Section 1176)

Knowingly Misusing PHI - $50,000, 1 year Misuse of PHI under False Pretenses -

$100,000 and up to 5 years Misuse of PHI with Intent to Sell - $250,000

and up to 10 years (Section 1777)

Because it’s the Law!

They say you should focus on four things:

What NC ITS Says You Should Do*

Based on November 2004 Risk Management policy issued by the State Chief Information Officer

*

1) Identification of Risks

2) Analysis of Risks

3) Mitigation Planning

4) Tracking and Controlling Risks

NC ITS’s Risk Management Program Consists of two components: Pre-Risk

Assessment, and Risk Assessment (three phases), explained in a Risk Management Guide

Phase I – Identify RisksPhase II – Analyze RisksPhase III – Manage Risks

Heavily uses the NIST rating scale:Low – Limited adverse effect on agencyModerate – Serious adverse effectHigh – Severe or catastrophic adverse effect

NC ITS’s RM – Pre-Risk Assessment Review lines of business service that have

automated systems that support the business service

Determine if critical infrastructures are involved, or if there are critical infrastructure dependencies

Complete the Pre-Risk Assessment form

NC ITS’s RM – Phase I A Facilitator leads a team of people

responsible for delivery of a particular line of business through completing the Phase I Questions of the ITS Risk Assessment Questionnaire

If the final score is “Low”, the risk assessment process ends

If the final score is “Moderate” or “High”, proceed to Phase II for additional analysis

NC ITS’s RM – Phase II A Facilitator leads a team of people

knowledgeable in the particular line of business through the Phase II Questions of the ITS Risk Assessment Questionnaire

If the final score is “Low”, the risk assessment process ends

If the final score is “Moderate” or “High”, proceed to Phase III for mitigation

NC ITS’s RM – Phase III A Facilitator leads appropriate managers and

staff through an analysis that focuses on mitigation

The team identifies options to mitigate the risk, analyzes the cost implications, determines the benefits, and balances the cost of implementing each option against the benefits derived from it

The result is completion of the Risk Analysis Results & Mitigation Plans form found in the ITS Risk Assessment Questionnaire

NC ITS’s Risk Management Training On March 31, 2004, ITS and its vendor

partner, Strohl Systems, presented a two hour agency training session (introduced by Ann Garrett) which covered both Business Impact Analysis and Risk Management

Let’s fast forward and view the Risk Management part of the PowerPoint slide show presented there

Let’s try working through an example

Pre-Risk Assessment Form

Line of Business – Pharmacy Business Process Owner – Pharmacy

Director Automated System Supporting – MCPlus Critical Infrastructure – Linux Server Critical Dependencies – Vendor

Risk Assessment Questionnaire 20 Phase I Questions (Q1 – Q19) If one or more questions is answered as

“Moderate” or “High”, then proceed to Phase II questions

65 Phase II Questions (Q1 – Q25) If one or more questions (except for Q3) is

answered as “Moderate” or “High”, then proceed to Phase III

Let’s try to fill out the Mitigation Plan now

(Based on June 15, 2005 DHHS Risk Management Policy)

What DHHS Says You Should Do Assign responsibility for managing risk to

senior management Provide a mechanism for tracking and

reporting risks Identify system threats in the environment Identify system vulnerabilities the threats

could attack Identify current security controls Identify current security gaps

DHHS Risk Management Policy, June 15, 2005More Things DHHS Says to Do

Ensure that every risk has at least one owner Develop the responses or controls necessary to

mitigate identified and reported risks Assess the probability of risks occurring and their

potential impact Identify the risks associated with critical processes

in the workflow Identify security controls currently implemented Provide an analysis of risks

DHHS Risk Management Policy, June 15, 2005

Even More Things DHHS Says to Do Ensure that Risk Management is an intrinsic

part of operations Keep Risk Management policies and

procedures current Perform an analysis to evaluate risk mitigation

actions taken, and to determine further steps Respond to changes in risks, and take

corrective action as needed

DHHS Information Security Management Policy, June 15, 2005

Even More Things DHHS Says to Do Implement a systematic, analytical and

continuous risk management program for information systems

Ensure that risk identification, analysis and mitigation activities are performed

Ensure that risk assessments are performed periodically to evaluate effectiveness of existing controls

Define strategies and mitigate risks to acceptable levels

DHHS Says to Address Risks by:

Risk Reduction – Implement measures to alter the risk position of an asset

Risk Transference – Assign or transfer the potential cost of the loss to another party

Risk Acceptance – Accept the level of loss that will occur and be prepared to absorb the loss

Confused Yet?ISO 17799HIPAA

NISTDHHS

MicrosoftWhat you thought

you knew

COBIT

Who Provides Us with the Most Help?

NIST Says

Risk Management has Three Parts Risk Assessment - Determining where risks

lie, and how big they are Risk Mitigation - Prioritizing, evaluating, and

implementing appropriate risk-reducing controls

Evaluation and Assessment – Since Risk Management is continuous and evolving, the past year’s Risk Management efforts should be assessed and evaluated prior to beginning the cycle again


Risk Assessment

Risk Mitigation

RM Evaluation

National Institute of Standards and Technology SP 800-30



1) System Characterization Define the boundaries of the IT system you

are addressing, along with the resources and the information that constitute the system, setting the scope of the assessment effort

Methods of gathering system characterization information include the use of questionnaires, interviews, and automatic scanning tools

Output #1: A system characterization paragraph

2) Threat Identification A threat is the potential for a particular

threat-source to successfully exercise a particular vulnerability

A threat-source is any circumstance or event with the potential to cause harm to an IT system

A vulnerability is a weakness that can be accidentally triggered or intentionally exploited

Two Types of Threat-Sources

1) Intent and method targeted at the intentional exploitation of a vulnerability

2) A situation and method that may accidentally trigger a vulnerability

Common Threat-Sources Natural Threats – Floods, earthquakes,

tornadoes, electrical storms, landslides, avalanches, etc.

Human Threats – Events either enabled or caused by human beings, including both unintentional acts (inadvertent data entry) and deliberate actions (unauthorized access)

Environmental Threats – Long-term power failure, pollution, chemicals, liquid leakage

Threat-Source Identification Humans are the most dangerous threat-source For each type of human threat-source,

estimate the motivation, resources, and capabilities that may be required to carry out a successful attack (to be used during the Likelihood Determination phase)

Output #2: A list of threats Output #3: A chart showing motivation and

necessary threat actions for human threats

3) Vulnerability Identification A vulnerability is a flaw or weakness in

system security procedures, design, implementation, or controls that could be exercised (accidentally triggered or intentionally exploited) and result in a security breach or a violation of an information security policy

Output #4: A list of vulnerabilities that could be exploited by the potential threat-sources

Where Vulnerabilities are Found1) Hardware Configuration – Servers,

Workstations, Routers, Switches, Firewalls

2) Software Applications – How installed, Where installed, Rights granted

3) IS Policies and Procedures – How complete, How up-to-date, How well known

4) Humans – Procedures not being followed, Staff not being trained

How We Find Vulnerabilities1) Hardware Configuration – Complete a System

Risk Analysis form for each network component, arrange for penetration testing

2) Software Applications – Complete an Application Criticality and Risk Analysis form for each application

3) IS Policies and Procedures – Complete a review of the quality of your Information Security Policies and Procedures every year

4) Humans – Review log files, training records, and incident reports

4) Control Analysis The goal of this step is to analyze the controls

that have been implemented to minimize the likelihood of a threat exercising a vulnerability

Output #5: A list of controls currently in use by network hardware components

Output #6: A list of controls currently in use by applications

5) Threat-Source/Vulnerability Pairs Considering the controls in place, what

are the Threat-source/Vulnerability pairs which are of most concern?

A vulnerability with no threat-source is not a risk

A threat-source with no vulnerability is not a risk

Output #7: A list of Threat-source and Vulnerability pairs of concern

6) Likelihood Determination A determination of the probability that a

potential vulnerability will be exercised When determining likelihood, consider:

1) Threat-source motivation and capability

2) The nature of the vulnerability

3) The existence and effectiveness of current controls

Likelihood Determination Results Output #8: For each identified vulnerability,

a determination of likelihood (H, M, or L)High – The threat-source is highly motivated and sufficiently

capable, and controls to prevent the vulnerability from being exercised are ineffective

Medium – The threat-source is motivated and capable, but controls are in place that may impede successful exercise of the vulnerability

Low – The threat-source lacks motivation or capability, or controls are in place to prevent or significantly impede exercising the vulnerability

7) Impact Analysis Determine the adverse impact

resulting from a successful threat exercise of each threat-source/vulnerability pair of concern

Adverse Impact Comes From: Loss of Integrity

- Improper modification

Loss of Availability- System cannot be accessed or data cannot be located

Loss of Confidentiality- Information classified as sensitive is disclosed without authorization

Impact Analysis Needs For an Impact Analysis we must know:1) The organization’s mission

2) The criticality of the data

3) The sensitivity of the data

Sensitivity is the sum of the potential injury from a breakdown in confidentiality

Criticality is the sum of the potential injury from a breakdown in integrity and/or availability

Impacts are High, Medium, or Low Output #9: For each identified vulnerability, an

estimation of the magnitude of probable impact

High – Exercise of the vulnerability may result in a highly costly loss or may significantly impede an organization’s mission or reputation

Medium – Exercise of the vulnerability may result in a costly loss or may harm an organization’s mission or reputation

Low – Exercise of the vulnerability may result in the loss of some assets, or may noticeably affect an organization’s mission or reputation

8) Risk Determination NIST says risk is the net mission impact

considering both the likelihood that a particular threat-source will exercise (accidentally trigger or intentionally exploit) a particular information system vulnerability, and the resulting impact on the organization if this should occur

Likelihood x Impact = Risk

Use a Risk-Level Matrix

ThreatLikelihood

ImpactLow(10)

Medium(50)

High(100)

High (1.0) Low10 x 1.0 = 10

Medium50 x 1.0 = 50

High100 x 1.0 = 100

Medium (0.5) Low10 x 0.5 = 5

Medium50 X 0.5 = 25

Medium100 x 0.5 = 50

Low (0.1) Low10 x 0.1 = 1

Low50 x 0.1 = 5

Low100 x 0.1 = 10

Risk Scale: High (>50 to 100); Medium (>10 to 50); Low (1 to 10)

Risk Scale and Necessary ActionsRisk Level Risk Description and Necessary Actions

High There is a strong need for corrective measures, the system may continue to operate, but a corrective action plan should be put in place as soon as possible

Medium Corrective actions are needed, and a plan incorporating these actions should be developed in a reasonable period of time

Low Additional controls may be implemented, or management may decide to accept this risk

Assessing the Risk Level Final determination of mission risk is derived

by multiplying the threat likelihood and the threat impact scores

Output #10: A numeric risk score for each identified vulnerability/threat-source pair

The Vulnerability Analysis form can be used to capture this information

9) Control Recommendations Finish your risk assessment by thinking of

controls which could help minimize the risk of the vulnerability/threat-source combinations you are most concerned about

To determine which controls are appropriate to add, perform a cost-benefit analysis

Output #11: Recommendation of additional controls based on risk assessment

10) Results Documentation The Risk Assessment report should be of

sufficient detail to allow the organization’s management to make informed decision on appropriate actions in response to the risks identified

Unlike an audit or investigative report that looks for “wrong-doing”, the Risk Assessment report should be not be presented in an accusatory manner

Risk Assessment Report Your Risk Assessment report should have:

A) An IntroductionB) A description of your Risk Assessment approachC) A system characterization summaryD) A list of Threat-SourcesE) Vulnerability/Threat-Source analysis resultsF) A summary of risk levels and recommendations

Output #12: Risk Assessment Report that measures risk and provides recommendations

Report - Introduction Purpose Scope Describe

* System Controls * Elements * Users * Site Locations * Other Details as necessary

Report – Risk Assessment Approach Describe Approach Used

Risk Assessment Team members

Techniques used to gather information(use of tools, questionnaires, etc.)

Development and description of risk scale (3x3, 4x4, or 5x5 risk level matrix)

Report – System Characterization Describe the system

- Hardware (server, router, switch) - Software (application, operating system) - System Interfaces (communication link) - Data - Users

Provide connectivity diagram or system input and output flowchart

Report - Threat Statement

Compile potential threat sources List associated threat actions Review Human Motivations

Report – Risk Assessment Results List observations (vulnerability/threat pairs) Observations contain

- Observation number and brief description- Discussion of threat-source and vulnerability- Identification of existing security controls- Likelihood discussion and evaluation- Risk rating- Recommended controls or alternative options

Report - Summary Total number of threat-source/vulnerabilities

pairs identified (“observations”) Summarize

- Observations- Associated risk levels- Recommendations- Any comments

Organize into a table to facilitate implementation

Reviewing NIST’s RA Output1) System Characterization

2) List of Threats

3) Human Motivation Review

4) List of Vulnerabilities

5) Review Network Hardware Controls

6) Review Application Controls

7) List Threat-Source and Vulnerability pairs

8) Likelihood determination for each pair of concern

9) Estimation of probable impact

10) Identify risk scores

11) Recommendations, if any, for additional controls

12) Risk Assessment Report


Risk Assessment

Risk Mitigation

Risk Mitigation Risk Mitigation is the process of identifying

areas of risk that are unacceptable; and estimating countermeasures, costs and resources to be implemented as a measure to reduce the level of risk

Determining “appropriate risk-reducing controls” is a job for your Risk Management Committee

What is “Acceptable” Risk? Setting your agency’s “risk appetite” is up to

your Director and Senior Management Because elimination of all risk is impossible,

we must use the least-cost approach and implement the most appropriate controls to decrease mission risk to an acceptable level, with minimal adverse impact on the organization’s resources and mission

Risk Mitigation Options Assume the Risk – Accept the risk and

continue operating (how big is your appetite?) Avoid the Risk – Stop running the program

or sharing the data Transfer the Risk – Use options to

compensate for the loss, such as insurance Lessen the Risk – Implement controls that

lessen the impact or lower the likelihood

Risk Mitigation Methodology1) Prioritize based on risk levels presented

2) Evaluate recommended control options

3) Conduct a cost-benefit analysis

4) Select additional controls, as necessary

5) Assign responsibility

6) Develop an action plan, if necessary

7) Implement the selected controls

Possible Technical Controls User Identification Security Administration Authentication Authorization Nonrepudiation Transaction Privacy Restore Secure State Virus Detection and Eradication

Possible Management Controls Assign Security Responsibility Conduct Security Awareness Training Conduct end-user training for system users Implement personnel clearance procedures Perform periodic system audits Conduct ongoing risk management activities Establish incident response capability

Possible Operational Controls Control physical access Secure hub and cable wiring closets Establish off-site storage procedures Provide an uninterruptible power supply Control temperature and humidity Provide motion sensors or CCTV monitoring Ensure environmental security

Cost-Benefit Analysis If control reduces risk more than needed, see

if a less expensive alternative exists If control would cost more than the risk

reduction provided, then find something else If control does not reduce risk sufficiently,

look for more controls or a different control If control provides enough risk reduction and

is cost-effective, then use it

When Should Management Take Action?

System Design

YES

NO

No Risk

YES

NO

No Risk

Vulnerability Exists

Threat Source

YES

Risk Accept

Unacceptable Risk

Risk Exists

YES

Risk Accept

&

NO NO

Attacker’s Cost < Gain

Loss Anticipated > Threshold

Flaw or weakness?

Can be exercised?

YES

NO

No Risk

Mission Impact?

Residual Risk The risk remaining after the implementation

of new or enhanced controls is the residual risk

If the residual risk has not been reduced to an acceptable level, the risk management cycle must be repeated to identify a way of lowering the residual risk to an acceptable level

Understand that no IT system can be risk-free


Risk Assessment

Risk Mitigation

RM Evaluation

Evaluation and Assessment People, systems, and networks change,

so risk management must be ongoing Federal agencies must conduct risk

management at least every three years Stay flexible to allow changes when

warranted

NIST Says

Good Risk Management Depends Upon

1) Senior management’s commitment2) Support of the IT Team3) Competence of the Risk Management

Committee4) The cooperation of the users5) Ongoing assessment of IT-related

mission risks

Risk Management ExamplesScenario #1 - The Grounds of My Home

#1) The Grounds of My Home1) System Characterization - the land my home

sits on (risk owned by my wife)2) Threat Identification – Environmental? From

people? From Nature?3) Vulnerability Identification – Looking for

weaknesses which could be exercised by a threat-source; use eyes and knowledge

4) Control Analysis – City Services, fire hydrant, Home Owner’s insurance, car insurance

The Grounds of My Home – Continued

5) Identify Threat-Source/Vulnerability Pairs – Dead limb or whole tree could fall on my car

6) Likelihood Determination – Has happened before; lots of storms; high likelihood

7) Impact Analysis – Dents, broken glass, car not drivable, repair cost – medium impact

8) Risk Determination – High (1.0) Likelihood x Medium (50) Impact = Medium (50) Risk

9) Control Recommendation Options:o Have wife pull the limb downo Hire a tree surgeon to take off the limbo Take the tree downo Don’t park thereo Park my wife’s company car thereo Buy a bicycleo Lower amount of deductible

The Grounds of My Home – Continued

Completing Mitigation . . Assign Responsibility

Taking down the limb - My wife (stronger)Parking differently - Me (get home first)

Develop an Action Plan (if necessary)This weekend--------------------------------------------------------

o Lessen the likelihood by removing the limbo Transfer some risk to my wife’s companyo Accept the residual risk

Risk Management ExamplesScenario #2 - The Agency File Servers

#2) The File Servers1) System Characterization - the File Servers in

our Server Closet2) Threat Identification – Environmental? From

people? From Nature?3) Vulnerability Identification – Looking for

weaknesses which could be exercised by a threat-source; use eyes and knowledge

4) Control Analysis – Firewall, Locks, Daily Observation, Separate Circuit, UPSs

The File Servers – Continued

5) Identify Threat-Source/Vulnerability Pairs – Big Oak could fall on flat roof, break it

6) Likelihood Determination – Tree appears strong, but lots of storms; low likelihood

7) Impact Analysis – Damage from impact, water damage, repair cost – high impact

8) Risk Determination – Low (0.1) Likelihood x High (100) Impact = Low (10) Risk

9) Control Recommendation Options:o Have the tree removedo Weaken the tree on the other side to affect fallo Relocate the File Serverso Reinforce the roofo Buy a tarp and rig it over the serverso Buy a tarp and keep it handy

The File Servers – Continued


LAN Manager - Buying a tarp at Wal-Mart for $9 Develop an Action Plan (if necessary)

Do it tomorrow

--------------------------------------------------------o Lessen the impact by preparing for the event

(even though it is unlikely)o Accept the residual risk

Risk Management ExamplesScenario #3 - An Agency Application

#3) An Agency Application1) System Characterization - Local Access-

based system with PHI sent over the internet2) Threat Identification – From people? From

telecommunication?3) Vulnerability Identification – Availability and

Integrity risks are low, but Confidentiality risk is high; also, data is sent elsewhere

4) Control Analysis – Logical and Physical Access controls, Security Awareness Program, Staff Sensitivity Designations

An Application – Continued

5) Identify Threat-Source/Vulnerability Pairs – We are sharing PHI with no Business Associate agreement in place

6) Likelihood Determination – Sent to another CE, but no BA in place; low likelihood

7) Impact Analysis – PHI becoming exposed could hurt image badly – high impact

8) Risk Determination – Low (0.1) Likelihood x High (100) Impact = Low (10) Risk

Control Recommendation Options: Make sure the receiver of the PHI

understands their BA responsibilities Offer training to the Business Associate Request written documentation for the

program Establish a written Memorandum of

Understanding between the agencies

An Application – Continued


Security Official will contact other Security OfficialSecurity Official will develop and offer training showData Owner will request software documentation

Develop an Action Plan (if necessary)--------------------------------------------------------

o Lessen the likelihood establishing a HIPAA compliant Business Associate relationship

o Accept the residual risk

So Let’s Go! All Set? - We know where we want to

go, and we have a map, so we’re ready, right?

Hold On – How long is this trip, and how old are we now?

Let’s estimate our organization’s risk management maturity, and our readiness

What is your Security Risk Management Maturity Level?

Based on ISO 17799

Which of these 6 levels best describes your organization?

Risk Management Maturity Levels

Level State Definition

0 Non-Existent

Policy is not documented, and previously the organization was unaware of the business risk associated with this risk management; therefore there has been no communication on the issue.

1 Ad-Hoc Some members of the organization have concluded that risk management has value, however, risk management efforts are performed in an ad-hoc manner. There are no documented processes or policies, and the process is not fully repeatable.



2 Repeatable There is awareness of risk management throughout the organization. The process is repeatable, but immature, and not fully documented. Implementation is left to individual employees.

3 Defined Process

The organization has made a formal decision to adopt risk management wholeheartedly in order to drive its information security program. There are clearly defined goals, and some risk management training is available for all staff.



4 Managed There is a thorough understanding of risk management at all levels of the organization. The process is well-defined, broadly communicated, and training is available. Some initial forms of measurement are in place

5 Optimized The organization has committed significant resources to risk management. The process is well-understood and somewhat automated. Training across a range of levels of expertise is available to staff.

What is your Security Risk Management Readiness Level?

Based on Microsoft’s Security Risk Management Guide – Chapter 3

The following test measures your organization’s readiness level

For each of these 17 questions, score your organization on a scale of zero to five, using the previous maturity level definitions as a guide

Risk Management Readiness Test1) Information security policies and procedures are

clear, concise, well-documented, and complete2) All staff positions with job responsibilities involving

information security have clearly articulated and well understood roles and responsibilities

3) Policies and procedures for securing third-party access to business data are well-documented. For example, remote vendors performing application development for an internal business tool have sufficient access to network resources to effectively collaborate and complete their work, but they have only the minimum amount of access that they need


Risk Management Readiness Test4) An inventory of Information Technology (IT) assets

such as hardware, software, and data repositories is accurate and up-to-date

5) Suitable controls are in place to protect business data from unauthorized access by both outsiders and insiders

6) Effective user awareness programs such as training and newsletters regarding information security policies and practices are in place

7) Physical access to the computer network and other information technology assets is restricted through the use of effective controls


Risk Management Readiness Test8) New computer systems are provisioned following

organizational security standards in a standardized manner using automated tools such as disk imaging or build scripts

9) An effective patch management system is able to automatically deliver software updates from most vendors to the vast majority of the computer systems in the organization

10) Effective user awareness programs such as training and newsletters regarding information security policies and practices are in place


11) The organization has a comprehensive anti-virus program including multiple layers of defense, user awareness training, and effective processes for responding to virus outbreaks

12) User provisioning processes are well documented and at least partially automated so that new employees, vendors, and partners can be granted an appropriate level of access to the organization's information systems in a timely manner. These processes should also support the timely disabling and deletion of user accounts that are no longer needed

Risk Management Readiness TestFrom Microsoft’s Security Risk Management Guide, Chapter 3

Risk Management Readiness Test13) Computer and network access is controlled

through user authentication and authorization, restrictive access control lists on data, and proactive monitoring for policy violations

14) Application developers are provided with education and possess a clear awareness of security standards for software creation and quality assurance testing of code

15) Business continuity and business continuity programs are clearly defined, well documented, and periodically tested through simulations and drills


Risk Management Readiness Test16) Programs have commenced and are effective for

ensuring that all staff perform their work tasks in a manner compliant with legal requirements

17) Third-party review and audits are used regularly to verify compliance with standard practices for security business assets


Add all 17 scores together< 34 Consider starting slowly by creating a Risk

Management team and applying the process to a single business unit of your organization

34 to 50

Your organization has taken many significant steps, and is ready to move forward and expose the entire organization to the process

> 50 Your organization is well-prepared to begin to use security risk management to its fullest extent

Are You Ahead or Behind?

0

1 0

2 0

3 0

4 0

5 0

6 0

7 0

8 0

1 9 9 6 2 0 0 0 2 0 0 5 2 0 0 8

B l i s s f u lI g n o r a n c e

A w a r e n e s sP h a s e

C o r r e c t i v eP h a s e

O p e r a t i o n sE x c e l l e n c e

According to the Gartner Group, using a population of G2000 type companies

So Let’s Go! All Set? - We know where we want to go, and we

have a map We know how mature we are, and have an idea about

the readiness of our organization to begin risk management

Can we kill any other birds with the same stones?

Related DHHS Policies “System owners are responsible for

determining the sensitivity of data and ensuring that adequate controls are implemented to protect the data.”DHHS Information Systems Review and Auditing Policy

“Tests that shall be included in overall security testing strategy for each Division/Offices shall include Vulnerability Scanning and Penetration Testing.”DHHS Security Testing Policy

Related DHHS Policies “The BC/DR planning team shall do the

following: Identify the types of disasters most likely to occur and the resultant impacts on the agency’s ability to perform its mission.”DHHS Business Continuity and Disaster Recovery Policy

“The BC/DR planning team shall do the following: Propose protective measures to be implemented in anticipation of a natural or man-made disaster.”DHHS Business Continuity and Disaster Recovery Policy

Related DHHS Policies “Plans shall include: A risk assessment to

determine risk priorities and probability of identified risk.”DHHS Business Continuity and Disaster Recovery Policy

“Plans shall include: Development of recovery/restoration procedures for time critical systems and applications.”DHHS Business Continuity and Disaster Recovery Policy

Related DHHS Policies For each application, classify the risk from loss

of confidentiality as “low”, “medium”, or “high For each application, classify the risk from loss

of integrity as “low”, “medium” or “high” For each application, classify the availability

need level as 1 (2 to 4 days), 2 (5 to 9 days), 3 (10 to 19 days) or 4DHHS Data Classification, Labeling and Access Control Policy

Related DHHS Policies “System Administrators have the

responsibility of periodically reviewing user access privileges and notifying management of any access concerns.”

“The system owner of each information system shall ensure that all user accounts are reviewed and access rights evaluated at least once per quarter.”DHHS User Authorization, Identification and Authentication Policy

More Related DHHS Policies “DHHS Divisions/Offices shall protect data

on all sensitive and critical applications/systems by implementing controls that are commensurate with the security level required to protect the data”

“If sensitive electronic data resides in a DHHS Division/Office, administrative, physical and technical security controls must be implemented to limit unauthorized access to the data”DHHS Data Protection Policy

More Related DHHS Policies “All technology shall be evaluated to

ensure that it can provide the level of security required.”

“Security risk in the operations environment shall be kept to a level that is considered “acceptable risk”DHHS IT Operations Security Policy

Related HIPAA Requirements Application and Data Criticality Analysis –

Assess the relative criticality of specific applications and data in support of other contingency plan componentsHIPAA Section 164.308 (a)(7)(ii)(E)

Emergency Mode Operation Plan – Establish procedures to enable continuation of critical business processes for protection of the security of electronic PHI while operating in emergency mode

HIPAA Section 164.308 (a)(7)(ii)(C)

Risk Analysis – A covered entity “must conduct an actual and thorough assessment of the potential risks and vulnerabilities of the confidentiality, integrity, and availability of electronic PHI held by the covered entity” Standard (a)(1)(2)(A)

Risk Management – A covered entity “must implement security measures sufficient to reduce risks and vulnerabilities to a reasonable and appropriate level” Standard (a)(1)(ii)(D)



12 Steps Towards YOUR Program1) Educate Management2) Locate all assets3) Assign all risk4) Complete Network

Risk Analysis forms5) Complete

Application Risk Analysis forms

6) Penetration and Vulnerability Testing

7) Update Threats list8) Review IS P&P9) Complete

Vulnerability Analysis forms

10) RM Committee meets and decides on additional controls

11) Report sent to Director12) RM mid-year meeting

1) Educate Management Risk Management is one of a half dozen

Information Security projects which Management must be educated about

Consider an Information Security Training for Management presentation

Risk Management MUST be driven by management if it is to be successful

Don’t neglect training for “middle” managers, including application owners and supervisors

2) Locate All Assets Hardware and Data - Start listing what you

know about, then find the rest Do searches on the network for file types Find out who has been storing data on local

hard drives (and stop it) List applications, including which have PHI Determine where Word, Excel, and Access

files with PHI are kept

3) Assign all Risk All applications have Data Owners If you created a file (not part of an application

program), then you own it If you own a file, you are responsible for

protecting it All network components – wiring, router,

switches, servers, concentrators – have a person assigned to them who owns the risk

4) Network Risk Analysis Forms Complete one form for

each type of component

1) Windows XP Workstations2) Windows 2000 workstations3) Windows 98 workstations4) File Servers5) Firewall6) Router7) Core Switch8) Workgroup Switches9) Wireless Segment, etc.

For Network Risk Analysis form instructions, click HERE

5) Application Risk Analysis Forms Complete one form

for each application

1) HEARTS2) MCPlus Pharmacy3) NC Accounting4) Personal Planning System5) NCSnap6) Restraint Tracking7) Staff Development

Records8) Staff Vacancies, etc.

For Application Risk Analysis form instructions, click HERE

6) Penetration and Vulnerability Tests DIRM may be willing to provide penetration

and vulnerability testing You may have to hire a firm to provide these

services Testing should be done from both inside your

firewall, and from outside your firewall If necessary, hire a teenager

7) Update Threats List Consider Natural Threats, Human Threats,

and Environmental Threats For Human Threats, consider sources of

motivation Your Threats List will not be identical to

others, since local factors must be considered Provide this updated list to your Risk

Management Committee each year

8) Review IS Policies and Procedures Many risks are inherent in the absence of

information security policies and procedures Procedures must evolve as new policies

develop and old policies change Your IS Policy and Procedure review should

be done by someone other than the agency’s Information Security Official

The results of this review are presented at the Risk Management Team meeting

9) Vulnerability Analysis Forms Complete one form for

each vulnerability/threat-pair combination

1) HEARTS PHI being disclosed to or by the Client Data Warehouse

2) Workgroup switch located in unlocked wiring closet

3) Loss of application availability due to file server running out of disk space

For Vulnerability Analysis form instructions, click HERE

10) Risk Management Team Meets RM Committee should be made up of senior

managers, such as the Assistant Director and Business Manager, and at least one information system owner

Team reviews all input, and makes decisions as to what additional cost-effective controls should be implemented

Educating this team is an important part of improving your risk management process

It is the Team’s experience that sets priorities

11) Send RM Report to the Director The Risk Management Report should clearly

list the vulnerability/threat-source pairings of concern, and any additional controls which are recommended

The report should ideally include a cover letter to the Director, signed by each member of the Committee

12) The Committee’s Mid-Year Meeting The Risk Management Committee should

meet at least twice each year The mid-year meeting should be concerned

about evaluating the results of the recommendations which emerged from the year’s first meeting, where mitigation measures were discussed and decided upon

Minutes of your Risk Management Committee meetings should be saved for 6 years

12 Steps Towards YOUR Program1) Educate Management2) Locate all assets3) Assign all risk4) Complete Network

Risk Analysis forms5) Complete

Application Risk Analysis forms

6) Penetration and Vulnerability Testing

7) Update Threats list8) Review IS P&P9) Complete

Vulnerability Analysis forms

10) RM Committee meets and decides on additional controls

11) Report sent to Director12) RM mid-year meeting

Risk Management Process Timeline

Implement Additional Controls

Risk Mitigation Meeting

Risk Management Mid-Year Meeting

Report Sent to Director

Penetration Testing

Network Risk Forms

Application Risk Forms

Update Threat List

Vulnerability Forms

What We Covered Today . . What Risk Management means What NIST says you should do What ISO 17799 says you should do What COBIT says you should do What Microsoft says you should do What HIPAA says you should do What NC ITS says you should do What DHHS says you should do Developing YOUR program in 12 steps

Links Found in this Slide ShowNISTNIST SP 800-12NIST SP 800-18NIST SP 800-26NIST SP 800-30ISOMicrosoft’s Security Risk Management GuideCOBITDHHS’s Risk ManagementITS’s November 2005 Risk Management

PolicyMaturity Level DefinitionsHIPAA Security RuleITS Risk Management SiteITS Risk Management Guide

ITS Pre-Risk Assessment FormITS RA QuestionnaireThreats ListHuman Motivations ListNetwork Risk Analysis FormInstructions for above formApplication Criticality and Risk Analysis

FormInstructions for above formVulnerability Analysis FormInstructions for above formTraining for Management ShowTraining for Supervisors ShowTraining for Application Owners Training for Users Show

Any Questions?

Developing an Information Technology Risk

Management Program

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