5-BPM004656 Solicitation Attachment 5 - Arizona Baseline Security Controls Assessment.xls

XLS spreadsheet 290 KB Posted

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Master Agreement AZ|CTR063768
Contract number
CTR063768
Issued by
Arizona

About this file

This document appears to be a comprehensive NIST 800-53 security controls assessment spreadsheet for ICM Document Solutions, specifically related to a state contract with Arizona. The document details a rigorous cybersecurity control review across multiple security domains including access control, awareness and training, audit and accountability, configuration management, contingency planning, identification and authentication, media protection, personnel security, risk assessment, system and services acquisition, system and communications protection, and system and information integrity.

The document does not contain explicit pricing, service amounts, or contract renewal terms. Instead, it provides a detailed technical assessment of ICM Document Solutions' information security practices, focusing on their ability to meet the State of Arizona's security baseline controls. The assessment covers various control implementations across different security categories, with ICM describing their specific approaches to managing system access, monitoring, vulnerability scanning, flaw remediation, personnel screening, and other critical security functions. The document indicates that ICM has largely implemented corporate and system-specific controls to meet the state's security requirements, with some controls being service provider specific and others requiring customer configuration or involvement.

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NIST 800-53 r4 controls

Req.#Security Control FamilyControl NameNIST
800-53 Control #Mandatory ControlsSecurity Program Area
(Function Area -> Functional Sub-Area)NIST 800-53 Rev. 4 Control

[Control and Control Enhancement]

Detailed breakdown of required controlsVendor's Response
(Please Address all the controls and control enhancements in DETAIL Controls and Enhancements identified in Column H)Overall Control(s)

Implementation Status (Reference on Comments Page )

Please select from Drop down (Lower right corner)Where does the Control(s) originate from?
Please select from Drop down (Lower right corner)Supporting

Documentation

(Policies and procedures must be explicitly referenced (title and date or version) so that it is clear which document is being referred to. Section numbers or similar mechanisms should allow the reviewer to easily find the reference.)Vendor's Compensating Controls
(if Control Can't Be Met - What is the alternative security controls employed by organization)Vendor Non-Compliance

(If you can't meet this control at all please explain why)

(Please See Risk Statement for examples of Non-Compliance language Column R)General Assessment QuestionsDetailed Control Testing Procedure(s)Risk Statement Examples
R0002ACCESS CONTROLACCOUNT MANAGEMENTAC-2RequiredProtect -> Access ControlThe organization:

a. Identifies and selects the following types of information system accounts to support organizational missions/business functions: [Assignment: organization-defined information system account types];

b. Assigns account managers for information system accounts;

c. Establishes conditions for group and role membership;

d. Specifies authorized users of the information system, group and role membership, and access authorizations (i.e., privileges) and other attributes (as required) for each account;

e. Requires approvals by [Assignment: organization-defined personnel or roles] for requests to create information system accounts;

f. Creates, enables, modifies, disables, and removes information system accounts in accordance with [Assignment: organization-defined procedures or conditions];

g. Monitors the use of, information system accounts;

h. Notifies account managers:

1. When accounts are no longer required;

2. When users are terminated or transferred; and

3. When individual information system usage or need-to-know changes;

i. Authorizes access to the information system based on:

1. A valid access authorization;

2. Intended system usage; and

3. Other attributes as required by the organization or associated missions/business functions;

j. Reviews accounts for compliance with account management requirements [At least annually]; and

k. Establishes a process for reissuing shared/group account credentials (if deployed) when individuals are removed from the group. ICM Document Solutions (ICM) utilizes user and administrator accounts to provide access to our or corporate network and resources(a) and has several designated IT Administrators that provide and maintain system accounts(b).

ICM has a process in place that defines group and role membership for corp users(c); has clearly defined membership for system administrators that provide user access to system resources(d) and ICM requires that account creation requests are made by authorized personnel i.e. managers(e).

ICM IT Systems Administrators have procedures in place to create, maintain and disable system accounts as circumstances warrant(f). ICM IT Administration Staff monitor account usage and will notify account managers when the original use of the account changes(g,h,1,2,3).

Access to ICM's information systems require an account name and secure password and are basesd on a user's need to execute their job functions(i,1,2,3).

ICM IT System Administrators actively monitor account usage and verifies if there are any changes to the account's purpose(j); ICM IT System Administrators have a process in place that defines when and how an individual is added back to security or distribution group if the individual had previously belonged to the group(k).ImplementedService Provider CorporateIT-0010_Rev1N/AN/AAre there processes in place to ensure access provided to users (e.g., the role provided to a user for an application, or privileged access provided to an IT administrator, etc.) aligns with business requirements and/or access control policy?
[Note: an example could be documented approval from asset/business owner, timely removal of access from transferred or terminated employees, etc.].Obtain access control policy; procedures addressing account management; security plan; list of active system accounts along with the name of the individual associated with each account; lists of recently transferred, separated, or terminated employees; list of recently disabled information system accounts along with the name of the individual associated with each account; system-generated records with user IDs and last login date; other relevant documents or records and ascertain if

(I) the organization manages information system accounts, including authorizing, establishing, activating, modifying, reviewing, disabling, and removing accounts;

(ii) the organization defines in the security plan, explicitly or by reference, the frequency of information system account reviews and the frequency is at least annually;

(iii) the organization reviews information system accounts in accordance with organization-defined frequency; and

(iv) the organization initiates required actions on information system accounts based on the review.

(v) determine if the organization employs automated mechanisms to support information system account management functions.

(vi) the organization defines in the security plan, explicitly or by reference, a time period for each type of account after which the information system terminates temporary and emergency accounts; and

(vii) the information system automatically terminates temporary and emergency accounts after organization-defined time period for each type of account.

(viii) the organization defines in the security plan, explicitly or by reference, a time period after which the information system disables inactive accounts; and

(ix) the information system automatically disables inactive accounts after organization-defined time period.

(x) the organization employs automated mechanisms to audit account creation, modification, disabling, and termination actions; and

(xi) the organization employs automated mechanisms to notify, as required, appropriate individuals.Unauthorized access is gained to information systems.
R0003ACCESS CONTROLACCESS ENFORCEMENTAC-3RequiredProtect -> Access ControlThe information system enforces approved authorizations for logical access to information and system resources in accordance with applicable access control policies.ICM’s network is secured from outside intrusion by enterprise‐level firewalls and Virtual Private Network(VPN) technology. ICM’s internal network utilizes Microsoft Active Directory which requires that all data resources (files and folders) can only be accessed by a (Windows) account’s security object or group permission level.
Access to ICM’s Active Directory network is strictly maintained through use of Microsoft Group Policies. All ICM data resides on suported Microsoft Windows File Servers. These servers are built on the NTFS file system, which are inherently secure, by use of Access Control Lists (ACL).ImplementedService Provider CorporateIT-0010_Rev1N/AN/AAre information systems (applications, operating systems, network devices, databases, etc.) configured and access enforcement mechanisms employed per approved policy to provide protection from unauthorized access by malicious users, software or systems?Obtain access control policy; procedures addressing access enforcement; information system configuration settings and associated documentation; list of assigned authorizations (user privileges); information system audit records; other relevant documents or records and ascertain if

(I) the information system enforces assigned authorizations for controlling access to the system in accordance with applicable policy; and

(ii) user privileges on the information system are consistent with the documented user authorizations.Misconfigured access controls provide unauthorized access to information held in application systems.
R0004ACCESS CONTROLINFORMATION FLOW ENFORCEMENTAC-4RequiredProtect -> Access ControlThe information system enforces approved authorizations for controlling the flow of information within the system and between interconnected systems based on [Assignment: organization-defined information flow control policies].ICM’s network utilizes Microsoft Active Directory which requires that all data resources (files and folders) can only be accessed by a (Windows) account’s security object or group permission level.
Access to ICM’s Active Directory network is strictly maintained through use of Microsoft Group Policies.ImplementedService Provider CorporateIT-0010_Rev1N/AN/ADoes the institution or department have policies and supporting processes in place:

1) to "authorize" and regulate connections to and from applicable information systems, and [Note: supporting processes can include security considerations when interfaces are created to and from the information system; controlling administrative type access that can enable interface accounts, etc.].

2) to restrict and control the allocation and use of administrative access to information systems?

[Note: examples may include approvals needed to grant administrative type access; monitoring for administrative access need and usage; etc.].Obtain access control policy; procedures addressing information flow enforcement; information system design documentation; information system configuration settings and associated documentation; information system baseline configuration; list of information flow authorizations; information system audit records; other relevant documents or records and ascertain if the information system enforces assigned authorizations for controlling the flow of information within the system and between interconnected systems in accordance with applicable policy.Users gain access to information that is beyond their appropriate level of privilege.
R0005ACCESS CONTROLSEPARATION OF DUTIESAC-5RequiredProtect -> Account ManagementThe organization:

a. Separates [Assignment: organization-defined duties of individuals];

b. Documents separation of duties of individuals; and

c. Defines information system access authorizations to support separation of duties.ICM clearly defines roles and job functions within and outside the organization. These roles and duties are defined in our control documentation. Access to ICM technical resources that are relevant to these job functions are restricted to only those accounts where access is required.ImplementedService Provider CorporateICM Document Solutions Quality Manual
ICM-0002_Rev_6_Quality_ManualN/AN/AHas the institution or department identified, documented, and separated duties of individuals (or roles) as necessary to prevent collusion or fraud If so, has such separation of duties been implemented through assigned information system access authorizations?
(Note: Fraud could occur when: administrator has ability to clear system logs; developers have update access to production systems; application roles where individual with access to accounts payable has access to cash accounts, etc.)Obtain access control policy; procedures addressing divisions of responsibility and separation of duties; information system configuration settings and associated documentation; list of divisions of responsibility and separation of duties; information system audit records; other relevant documents or records and ascertain if

(I) the organization establishes appropriate divisions of responsibility and separates duties as needed to eliminate conflicts of interest in the responsibilities and duties of individuals; and

(ii) the information system enforces separation of duties through assigned access authorizations.The lack of user segregation of duties may result in unauthorized or unintentional modification or misuse of the organization's information assets.
R0006ACCESS CONTROLLEAST PRIVILEGEAC-6RequiredProtect - Account ManagementThe organization employs the principle of least privilege, allowing only authorized accesses for users (or processes acting on behalf of users) which are necessary to accomplish assigned tasks in accordance with organizational missions and business functions.Access to ICM's information systems require an account name and secure password and are basesd on a user's need to execute their job functions.
ICM IT System Administrators actively monitors and logs account usage and modifcation and verifies if there are any changes to the account's purpose. Permission audits are performed bi-annually.ImplementedService Provider CorporateICM Document Solutions Quality Manual
ICM-0002_Rev_6_Quality_ManualN/AN/AHas the institution or department established and implemented procedures to restrict system access to only authorized personnel based on need to know and to other information systems based on business function requirements? [Note the organization may need to control access to facilities, information inside applications, software programs for testing and revision.]Obtain access control policy; procedures addressing least privilege; list of assigned access authorizations (user privileges); information system configuration settings and associated documentation; information system audit records; other relevant documents or records and ascertain if

(I) the organization assigns the most restrictive set of rights/privileges or accesses needed by users for the performance of specified tasks; and

(ii) the information system enforces the most restrictive set of rights/privileges or accesses needed by users.Information in applications is accessed by users and support personnel outside of defined business requirements.
R0013ACCESS CONTROLREMOTE ACCESSAC-17RequiredProtect -> Portable & Remote ComputingThe organization:

a. Establishes and documents usage restrictions, configuration/connection requirements, and implementation guidance for each type of remote access allowed; and

b. Authorizes remote access to the information system prior to allowing such connections.ICM IT System Administrators actively monitor account usage and verifies if there are any changes to the account's purpose. ICM IT System Administrators have a process in place that defines when and how an individual is added back to security or distribution group if the individual had previously belonged to the group.ImplementedService Provider CorporateICM Document Solutions Quality Manual
ICM-0002_Rev_6_Quality_ManualN/AN/ADoes the institution or department have policies and processes in place for:

(i) providing secure remote access to information systems, including rules on when privileged access is provided,

(ii) monitoring and authorizing remote access to information systems, and

(iii) enforcing requirements for remote connections to the information system in place?

[Note: Documentation on methods should also include usage restrictions and implementation guidance for each allowed remote access method; secure remote connections include proper configuration and use of encryption; example of privileged remote access include approval(s) required based on business need, and use of stronger authentication such as two-factor]. Obtain access control policy; procedures addressing remote access to the information system; information system configuration settings and associated documentation; information system audit records; other relevant documents or records and ascertain if

(I) the organization authorizes, monitors, and controls remote access to the information system for all allowed methods of remote access to include both establishment of the remote connection and subsequent user actions across that connection.

(ii) the information system employs automated mechanisms to facilitate the monitoring and control of remote access methods.

(iii) the information system employs cryptography to protect the confidentiality and integrity of remote access sessions.Users of corporate information systems expose business information to exploitable vulnerabilities when using teleworking solutions.
R0014ACCESS CONTROLWIRELESS ACCESSAC-18RequiredProtect -> Security Systems ManagementThe organization:

a. Establishes usage restrictions, configuration/connection requirements, and implementation guidance for wireless access; and

b. Authorizes wireless access to the information system prior to allowing such connections.

. ICM’s wireless access points are strictly managed by enterprise-level equipment. Additionally, wireless access is heavily restricted and requires ICM-Managed equipment and credentials to access. AES-256 is standard. Implemented Service Provider Corporate IT-0010_Rev1 N/A N/A Are wireless device(s) and access point(s) securely managed through:

(i) a defined and effective process for authorizing the setting up of wireless access points;

(ii) a defined and documented standard for configuring wireless access points for security;

(iii) having in place a process to regularly review wireless access points for proper configuration and rogue wireless access points; and

(iv) having a defined architecture where wireless access points are properly segregated from wired network (e.g., use of Firewalls)? Obtain access control policy; procedures addressing wireless implementation and usage (including restrictions); NIST Special Publications 800-48 and 800-97; activities related to wireless authorization, monitoring, and control; information system audit records; other relevant documents or records and ascertain if

(I) the organization establishes usage restrictions and implementation guidance for wireless technologies;

(ii) the organization authorizes, monitors, and controls wireless access to the information system; and

(iii) the wireless access restrictions are consistent with NIST Special Publications 800-48 and 800-97.

(iv) the organization uses authentication and encryption to protect wireless access to the information system.Unauthorized parties gain access to resources by exploiting vulnerabilities in unsecured wireless networks.
R0015ACCESS CONTROLACCESS CONTROL FOR MOBILE DEVICESAC-19RequiredProtect -> Access Control & MediaThe organization:

a. Establishes usage restrictions, configuration requirements, connection requirements, and implementation guidance for organization-controlled mobile devices; and

b. Authorizes the connection of mobile devices to organizational information systems. In some cases, ICM provides company-managed laptops for employee use. Employees have no reasonable expectation of privacy in regard to the use of such devices, and all use is subject to monitoring, to the maximum extent permitted by applicable law. This includes as permitted the right to monitor personal communications as necessary.

Email communications sent via a PCD is also subject to monitoring if sent through the ICM's networks and the PCD must allow ICM IT to manage the account on the device before it is provisioned.

All conversations, text messages and e-mails must be professional. When sending a text message or using a PCD for business purposes, whether it is a ICM-provided or personal device, employees must comply with applicable ICM guidelines, including policies on sexual harassment, discrimination, conduct, confidentiality, equipment use and operation of vehicles.

Using a Company-issued PCD to send or receive personal text messages is prohibited at all times and personal use during working hours should be limited to emergency situations. If an employee who uses a personal PCD for business resigns or is terminated, the employee will be required to submit the device to the IT department for resetting on or before his or her last day of work. At that time, the IT department will reset and remove all information from the device, including but not limited to, Company information and personal data (such as contacts, e-mails and photographs). The IT department will make efforts to provide employees with the personal data in another form (e.g., on a disk) to the extent practicable; however, the employee may lose some or all personal data saved on the device.

Employees may not use their personal PCD for business unless they agree to allow ICM IT department to manage the account on the device. This form of management is crucial to ensure compliance with the Company's confidentiality and proprietary information policies and objectives.

Please note that whether employees use their personal PCD or a Company-issued device, ICM's electronic communications policies, including but not limited to, proper use of communications and computer systems, remain in effect.ImplementedService Provider CorporateICM_Conversions_Inc_Multi_11-30-16_RM_FINAL.PDF"
ICM Employee Handbook located in our Employee PortalN/AN/AAre there documented policies, standards, and procedures in place for addressing and enforcing security related to usage of mobile devices (e.g., USB drives, PDAs, Smart Phones, tablets, etc.), including Bring Your Own Device (BYOD)?

[Note: Example controls include: policies that define how such devices are used in context of business; and technical controls such as password requirements to access the device, use of "containers" to segregate confidential information, use of encryption on containers, remote wipe-out capabilities for PDAs/Smartphones, etc.] Obtain access control policy; procedures addressing access control for portable and mobile devices; information system design documentation; information system configuration settings and associated documentation; information system audit records; other relevant documents or records and ascertain if

(I) the organization establishes usage restrictions and implementation guidance for organization-controlled portable and mobile devices; and

(ii) the organization authorizes, monitors, and controls device access to organizational information systems.Mobile computing and teleworking expose systems and information to exploitable vulnerabilities.
R0020AWARENESS AND TRAININGSECURITY AWARENESS TRAININGAT-2RequiredProtect -> Security Awareness and TrainingThe organization provides basic security awareness training to information system users (including managers, senior executives, and contractors):

a. As part of initial training for new users;

b. When required by information system changes; and

c. [Assignment: organization-defined frequency] thereafter. ICM Team Managers proactively advance information security concerns across the organization to address actual and/or potential incidents. Activities include:

- Communicate concerns

- Contribute to resource planning through risk assessment or other means

- Participate in training and awareness initiatives ICM team members participate in information security awareness training and comply with safeguards. Incidents are reported to team leads and/or managers as appropriate to:

- Prevent security breaches, if possible

- Mitigate security breaches

- Contain security threats

- Document incident

- Provide for Corrective / Preventive action Implemented Service Provider Corporate ICM-0041_Rev_1 Section 4 N/A N/A 1. Does the institution or department provide on-going basic security awareness training to all information system users (including department heads, senior executives, and contractors)? Are awareness and training materials updated periodically for addressing relevant security behaviors of the current time based on industry trends, past incidents, etc., as well as indicators of insider threat?

2. Does the organization have targeted training in place for positions with higher risk profile (e.g., system administrators, personnel with access to student records, etc.? Obtain Security awareness and training policy; procedures addressing security awareness training implementation; NIST Special Publication 800-50; appropriate codes of federal regulations; security awareness training curriculum; security awareness training materials; security plan; other relevant documents or records and ascertain if (I)the organization provides basic security awareness training to all information system users (including managers and senior executives) before authorizing access to the system and when required by system changes;

(ii)the security awareness training is consistent with applicable regulations and NIST Special Publication 800-50;

(iii)the security awareness and training materials address the specific requirements of the organization and the information systems to which personnel have authorized access;

(iv)the organization defines in the security plan, explicitly or by reference, the frequency of refresher security awareness training and the frequency is at least annually.

(v)the organization provides refresher security awareness training in accordance with organization-defined frequency.Employees, contractors or third party users breach security because they are not aware or trained on information security requirements.
R0028AUDIT AND ACCOUNTABILITYAUDIT REVIEW, ANALYSIS, AND REPORTINGAU-6RequiredProtect -> Audit Logging and Security Event Management & MediaThe organization:

a. Reviews and analyzes information system audit records [Assignment: organization-defined frequency] for indications of Parameter: [at least weekly]; and

b. Reports findings to [Assignment: organization-defined personnel or roles]. ICM's IT Administrators coordinate activities to regularly audit the data security processes as appropriate and maintains records as needed to demonstrate effectiveness. ICM's IT Administrators coordinate activities to regularly test the data security mechanisms as appropriate and maintains records as needed to demonstrate effectiveness.

Incidents are reported to team leads and/or managers as appropriate to:

- Prevent security breaches, if possible

- Mitigate security breaches

- Contain security threats

- Document incident

- Provide for Corrective / Preventive actionImplementedService Provider CorporateICM-0023_Rev_3 Section GN/AN/AAre information system audit records reviewed and analyzed on a daily basis for indications of inappropriate or unusual activity, findings reported to designated organizational officials, and corrective action plans implemented for identified issues?
[e.g., logs from different system correlated in order to effectively detect potential security issues; specific use cases for alerts been defined in order to identify critical security events; there are knowledgeable resources that exist and are responsible for responding to alerts; such process is tied to the incident response process]Obtain audit and accountability policy; procedures addressing audit monitoring, analysis, and reporting; threat information documentation from law enforcement, intelligence community, or other sources; information system configuration settings and associated documentation; information system audit records; reports of audit findings; records of actions taken in response to reviews/analyses of audit records; other relevant documents or records and ascertain if :

(I)the organization regularly reviews/analyzes audit records for indications of inappropriate or unusual activity;

(ii)the organization investigates suspicious activity or suspected violations;

(iii)the organization reports findings of inappropriate/unusual activities, suspicious behavior, or suspected violations to appropriate officials; and

(iv)the organization takes necessary actions in response to the reviews/analyses of audit recordsAudit findings are not effectively communicated or resolved by management.
R0033AUDIT AND ACCOUNTABILITYAUDIT GENERATIONAU-12RequiredProtect -> Audit Logging and Security Event Management & MediaThe information system:

a. Provides audit record generation capability for the auditable events defined in AU-2 a. at [all information system and network components where audit capability is deployed/available]

b. Allows [Assignment: organization-defined personnel or roles] to select which auditable events are to be audited by specific components of the information system; and

c. Generates audit records for the events defined in AU-2 d. with the content defined in AU-3. ICM's IT Administrators coordinate activities to regularly audit the data security processes as appropriate and maintains records as needed to demonstrate effectiveness. ICM's IT Administrators coordinate activities to regularly test the data security mechanisms as appropriate and maintains records as needed to demonstrate effectiveness.

Incidents are reported to team leads and/or managers as appropriate to:

- Prevent security breaches, if possible

- Mitigate security breaches

- Contain security threats

- Document incident

- Provide for Corrective / Preventive action Implemented Service Provider Corporate ICM-0041_Rev_1 N/A N/A Does the institution or department have a documented logging standard that defines the minimum requirements for logging (e.g., fields to log, type of events, log protection requirements, retention requirements, etc.)? Obtain audit and accountability policy; procedures addressing audit record generation; security plan; information system design documentation; information system configuration settings and associated documentation; information system audit records; other relevant documents or records and ascertain if :

(I) the organization defines the information system components that provide audit record generation capability for the list of auditable events defined in AU-2;

(ii) the information system provides audit record generation capability, at organization-defined information system components, for the list of auditable events defined in AU-2;

(iii) the information system allows designated organizational personnel to select which auditable events are to be audited by specific components of the system; and

(iv) the information system generates audit records for the list of audited events defined in AU-2 with the content as defined in AU-3.Failure to plan and execute IT audit activities may result in potential compromise of critical business processes and sensitive data to go undetected.
R0035SECURITY ASSESSMENT AND AUTHORIZATIONSECURITY ASSESSMENTSCA-2RequiredIdentify -> Security Assessment and Authorization / Technology Risk AssessmentsThe organization:

a. Develops a security assessment plan that describes the scope of the assessment including:

1. Security controls and control enhancements under assessment;

2. Assessment procedures to be used to determine security control effectiveness; and

3. Assessment environment, assessment team, and assessment roles and responsibilities;

b. Assesses the security controls in the information system and its environment of operation[at least annually] to determine the extent to which the controls are implemented correctly, operating as intended, and producing the desired outcome with respect to meeting established security requirements;

c. Produces a security assessment report that documents the results of the assessment; and

d. Provides the results of the security control assessment to [individuals or roles to include ADOA/ASET]. ICM's IT Administration serves as a business unit in providing software products and support services. It also provides corporate business information management including, but not limited to, technical support, software installation, new equipment, re-distribution of existing equipment, order fulfillment, training, etc.

ICM's IT creates or develops complete software, hardware, and/or business process solutions. These projects are typically software products or custom solutions that require a project plan and design reviews at suitable stages of development.

ICM's IT creates implementations of software, hardware, and/or business process solutions. These implementations usually have flexible constraints.

ICM's IT creates implementations for integrating software, hardware, and/or process solution tools in support of other ICM business units as standalone programs or with suitable interfacing to customer-based or vendorbased systems or tools.

ICM's IT provides consultative guidance in support of other ICM business units for addressing IT-sensitive, innovative solutions to customer/client services.

ICM's IT administers design, specification, and ongoing maintenance of computer systems, to include servers, networks, and related peripherals, including power, environmental, and security considerations. Implemented ICM-0023_Rev_3 Sections 1 and 2 N/A N/A Does the institution or department have a defined information security program that includes:

i) developing a plan and executing periodic assessments of security control effectiveness;

ii) identifying objective and qualified assessors; and iiI) reporting results of such assessment(s) to the appropriate stakeholders? Obtain security assessment policy; procedures addressing security assessments; security plan; security assessment plan; security assessment report; assessment evidence; security authorization package (including security plan, security assessment report, plan of action and milestones, authorization statement); other relevant documents or records and ascertain if :

(I)the organization defines in the security plan, explicitly or by reference, the frequency of security control assessments and the frequency is at least annually (ii)the organization conducts an assessment of the security controls in the information system at an organization-defined frequency.

(iii)the organization employs an independent assessor or assessment team to conduct an assessment of the security controls in the information system.Independent reviews of information security are not regularly performed to ensure the continuing suitability, adequacy, and effectiveness of the organization's information security program.
R0039SECURITY ASSESSMENT AND AUTHORIZATIONCONTINUOUS MONITORINGCA-7RequiredIdentify-> Control Oversight and Safeguard Assurance & Security Compliance and Regulatory Requirements ManagementThe organization develops a continuous monitoring strategy and implements a continuous monitoring program that includes:

a. Establishment of [Assignment: organization-defined metrics] to be monitored;

b. Establishment of [Assignment: organization-defined frequencies] for monitoring and [Assignment: organization-defined frequencies] for assessments supporting such monitoring;

c. Ongoing security control assessments in accordance with the organizational continuous monitoring strategy;

d. Ongoing security status monitoring of organization-defined metrics in accordance with the organizational continuous monitoring strategy; [To meet State of Arizona's requirements]

e. Correlation and analysis of security-related information generated by assessments and monitoring;

f. Response actions to address results of the analysis of security-related information; and

g. Reporting the security status of organization and the information system to [Assignment: organization-defined personnel or roles] [Assignment: organization-defined frequency]. ICM IT administers design and provide ongoing maintenance of infrastructure related to business access, to include facility badge access for staff as well as security monitoring devices.

ICM IT reviews risk management aspects associated with business information systems as appropriate, conducting tests/drills as warranted to ensure company data can be recovered in the event of a disaster or equipment failure.

ICM IT Maintains corrective action records via IT Helpdesk or CAPA.

ICM IT Logs incidents, as appropriate, to Security Incident Log ICM IT monitors performance of business information management activities against evaluative norms and metrics, as appropriate. Implemented ICM-0041_Rev_1 N/A N/A Has the institution or department implemented a continuous monitoring program that includes configuration management, ongoing security control assessments, and reporting on the information system and its constituent components? Obtain certification and accreditation policy; procedures addressing continuous monitoring of information system security controls; NIST Special Publications 800-37 and 800-53A; security plan; security assessment report; plan of action and milestones; information system monitoring records; security impact analyses; status reports; security plan; other relevant documents or records and ascertain if:

(I)the organization monitors the security controls in the information system on an ongoing basis.

(ii)the organization employs a security control monitoring process consistent with NIST Special Publications 800-37 and 800-53A.

(iii)the organization conducts security impact analyses on changes to the information system.

(iv)the organization documents and reports changes to or deficiencies in the security controls employed in the information system.Known violations of security policy are not properly mitigated due to ineffective compliance and/or self-assessment activities.
R0047CONFIGURATION MANAGEMENTCONFIGURATION SETTINGSCM-6RequiredProtect -> Secure Configuration Management & Change Management

Identify -> Critical Information Asset Inventory The organization:

a. Establishes and documents configuration settings for information technology products employed within the information system using [State of Arizona Configuration Baseline (SACB)] that reflect the most restrictive mode consistent with operational requirements;

b. Implements the configuration settings;

c. Identifies, documents, and approves any deviations from established configuration settings for [Assignment: organization-defined information system components] based on [Assignment: organization-defined operational requirements]; and

d. Monitors and controls changes to the configuration settings in accordance with organizational policies and procedures. ICM's IT Administrators document and maintain security configuration information in the following cases:

o Personnel key lock and photo-ID badge/key card access controls o Facility security credentials, such as security clearances o Personnel security credentials, such as security clearances o LAN server and support system with appropriate physical /connectivity access restrictions, environmental features, malicious software protections, security reminders, encryption capability, and firewall protections o LAN and PC user access rights, duties, and privileges control via log-in and password protocols o Workstation use and restrictions, as appropriate

Contracting services and/or third-party agreements and related security considerations, including:

- Access restrictions and revocation provisions

- Confidentiality Agreement(s) or NDAs

- Intellectual property rights (IPR) Information and data access protocols, including:

- PC user practices, including clear desk/clear screen considerations

- Rules for electronic mail and Internet usages

- Guidelines for the use of mobile devices especially for use outside ICM premises e.g. notebooks, palmtops, lap tops, smart cards, and mobile phones,

- Camera and cell phone (Smartphones) practices

- Personal Data Assistant (PDA), Portable media (flash drives), home computers or other non corporate equipment, or other devices Incident protocols, including:

- Incident response and reporting

- Incident investigations

- Corrective Action / Preventive Action Information security training, including:

- OPSEC awareness (Operational Security)

- Establishing priorities and budget

- Setting goals and objectives

- Providing guidance on curricula

- Maintaining records Information security metrics to aid in demonstrating effectiveness over time, including:

o LAN system uptime o Data breach incidents

5. The Corporate Security Officer or designate conducts and maintains security risks assessment(s),, as appropriate, to identify vulnerabilities of systems and threats to assets with plans and/or controls to prevent or mitigate incidents.

6. The Corporate Security Officer or designate develops and maintains additional processes and controls as appropriate. Plans may include:

o Asset Inventory(s) and ownership o Asset decommissioning and disposal o Business Continuity Plan, ICM-0042 o Disaster Recovery Planning o Emergency Response Planning o Functional proxy (per procurationem) o IT Information/Security Audit Plan o

7. The Corporate Security Officer or designate coordinates activities to regularly audit the data security processes as appropriate and maintains records as needed to demonstrate effectiveness and/or CA/PA.

8. The Corporate Security Officer or designate coordinates activities to regularly test the data security mechanisms as appropriate and maintains records as needed to demonstrate effectiveness and/or CA/PA.

9. Team Managers proactively advance information security concerns across the organization to address actual and/or potential incidents. Activities include:

o Communicate concerns o Contribute to resource planning through risk assessment or other means o Participate in training and awareness initiatives

10. ICM team members participate in information security awareness training and comply with safeguards. Incidents are reported to team leads and/or managers as appropriate to:

o Prevent security breaches, if possible o Mitigate security breaches o Contain security threats o Document incident o Provide for Corrective / Preventive action Implemented Service Provider Corporate ICM-0041_Rev_1 Sections C, D and E N/A N/A Does the institution or department have processes in place to monitor and control changes to the baseline configuration settings of information systems in accordance with organizational policies and procedures? Obtain configuration management policy; procedures addressing configuration settings for the information system; information system configuration settings and associated documentation; NIST Special Publication 800-70; other relevant documents or records and ascertain if:

(I)the organization establishes mandatory configuration settings for information technology products employed within the information system.

(ii)the organization configures the security settings of information technology products to the most restrictive mode consistent with operational requirements.

(iii)the organization documents the configuration settings.

(iv)the organization enforces the configuration settings in all components of the information system.Changes to the production environment are not operating as expected disrupt the production environment.
R0048CONFIGURATION MANAGEMENTLEAST FUNCTIONALITYCM-7RequiredProtect -> Secure Configuration Management & Change Management

Protect -> Network Access and Perimeter Controls The organization:

a. Configures the information system to provide only essential capabilities; and

b. Prohibits or restricts the use of the following functions, ports, protocols, and/or services: [Assignment: organization-defined prohibited or restricted functions, ports, protocols, and/or services].ICM clearly defines roles and job functions within and outside the organization. These roles and duties are defined in our control documentation. Access to ICM technical resources that are relevant to these job functions are restricted to only those accounts where access is required.ImplementedService Provider CorporateICM Document Solutions Quality Manual
ICM-0002_Rev_6_Quality_ManualN/AN/ADo the institution or department's configuration management procedures include processes for providing only essential functionality and restrict the use of functionality, ports, protocols, and/or services based on risk?Obtain configuration management policy; procedures addressing least functionality in the information system; security plan; information system configuration settings and associated documentation and ascertain if:

(I)the organization defines in the security plan, explicitly or by reference, prohibited or restricted functions, ports, protocols, and services for the information system.

(ii)the organization configures the information system to provide only essential capabilities.

(iii)the organization configures the information system to specifically prohibit and/or restrict the use of organization-defined functions, ports, protocols, and/or services.

(iv)the organization defines in the security plan, explicitly or by reference, the frequency of the information system reviews to identify and eliminate unnecessary functions, ports, protocols, and services; and

(v)the organization reviews the information system to identify and eliminate unnecessary functions, ports, protocols, and/or services in accordance with organization-defined frequency.Configuration standards do not exist for systems being implemented.
R0049CONFIGURATION MANAGEMENTINFORMATION SYSTEM COMPONENT INVENTORYCM-8RequiredIdentify -> Data Classification

Identify -> Critical Information Asset Inventory The organization:

a. Develops and documents an inventory of information system components that:

1. Accurately reflects the current information system;

2. Includes all components within the authorization boundary of the information system;

3. Is at the level of granularity deemed necessary for tracking and reporting; and

4. Includes [Assignment: organization-defined information deemed necessary to achieve effective information system component accountability]; and

b. Reviews and updates the information system component inventory [At least monthly]. ICM's IT Department documents, develops and maintains an inventory of IT resources. This information is updated regularly and is used to properly identify the stakeholders and responsible parties for these assets.

ICM's IT Department develops and maintains additional processes and controls as appropriate. Plans may include:

o Asset Inventory(s) and ownership o Asset decommissioning and disposal o Business Continuity Plan;

o Functional proxy (per procurationem) o Emergency Response Planning o Disaster Recovery Planning o IT Information/Security Audit Plan o Statement of Applicability (SOA) Implemented Service Provider Corporate ICM-0041_Rev_1 N/A N/A 1) Does the institution or department assign owner and custodian to all information and IT assets, and is there an approved document which describes and distinguishes the roles and responsibilities of an owner, custodian, and user? 2) Is there a current and accurate inventory of systems, that provides details such as associated owners, location, security requirements, data classification, etc., for the department? Obtain configuration management policy; procedures addressing information system component inventory; information system inventory records; security plan; component installation records; other relevant documents or records and ascertain if :

(I)the organization develops and documents an inventory of the components of the information system:

-that is at the level of granularity deemed appropriate by the organization for the components included in the inventory that are subject to tracking and reporting.

-that includes any information determined to be necessary by the organization to achieve effective property accountability.

-that is consistent with the accreditation boundary of the system.

(ii)the organization maintains the inventory of the components of the information system to reflect the current state of the system.

(iii)the organization updates the inventory of information system components as an integral part of component installations.Information and assets associated with information processing facilities are not owned by a designated part of the organization.
R0060CONTINGENCY PLANNINGINFORMATION SYSTEM BACKUPCP-9RequiredProtect -> Contingency PlanningThe organization:

a. Conducts backups of user-level information contained in the information system [daily incremental; weekly full];

b. Conducts backups of system-level information contained in the information system [daily incremental; weekly full]];

c. Conducts backups of information system documentation including security-related documentation [daily incremental; weekly full]; and

d. Protects the confidentiality, integrity, and availability of backup information at storage locations. ICM Document Solutions has a corporate backup policy. ICM backs up all user, and system level data and maintains documentation that provides the information to recover information from backups. ICM backups are located on secured (encrypted at rest) storage locations and are only accessable by authorized personnel. Implemented Service Provider Corporate ICM-0010_Rev1 N/A N/A Does the institution or department backup user-level and system-level information, system documentation, and security-related documentation consistent with recovery objectives and protect the confidentiality and integrity of backups? Obtain contingency planning policy; contingency plan; procedures addressing information system backup; security plan; backup storage location(s);information system backup test results; other relevant documents or records and ascertain if :

(I)the organization defines the frequency of information systems backups.

(ii)the organization backs up user-level and system-level information (including system state information) in accordance with the organization-defined frequency.

(iii)the organization backs up information to alternate storage sites (if so designated) at a frequency and transfer rate consistent with the organization’s recovery time objectives and recovery point objectives.

(iv)the organization protects backup information at the designated storage locations.

(v)the organization defines in the security plan, explicitly or by…

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