ICU_Boom_Attachment_Number_3.pdf

Attachment ICU Nursing and Respiratory Boom Security and Privacy

3: Terms and Conditions sor..PloTrt, .)r! IT SECURITY & PRIVACY A...TP(7AS HH

HHS CYBERSECURITY PROGRAM

OFFICE OF THE CHIEF INFORMATION OFFICER

ecunty ails rivacy anguage Information and Informatio Technology Procure ersion 2.

Security and, Privacy Guide for Information Technology Acquisition v2

A. Baseline Security Requirements

1) Applicability. The requirements herein apply whether the entire contract or order (hereafter "contract"), or portion thereof, includes either or both of the following:

a. Access (Physical or Logical) to Government Information: A Contractor (and/or any subcontractor) employee will have or will be given the ability to have, routine physical (entry) or logical (electronic) access to government information. Contractor personnel who need to be on-site to perform service and maintenance must be escorted and monitored at all times. A NDA must be signed if services and maintenance requires access PIT/PHI or sensitive government information.

b. Operate a Federal System Containing Inforr ation: A Contractor (and/or any subcontractor) will operate a federal system and information technology containing data that supports the fITIS mission. In addition to the Federal Acquisition Regulation (FAR) Subpart 2.1 definition of "information technology" (IT), the term as used in this section includes computers, ancillary equipment (including imaging peripherals, input, output, and storage devices necessary for security and surveillance), peripheral equipment designed to be controlled by the central processing unit of a computer, software, firmware and similar procedures, services (including support services), and related resources.

2) Safeguarding Information and Information Systems. In accordance with the Federal Information Processing Standards Publication (FIPS)199, Standards for Security Categorization of Federal Information and Information Systems, the Contractor (and/or any subcontractor) shall:

a. Protect government information and information systems in order to ensure:

• Confidentiality, which means preserving authorized restrictions on access and disclosure, based on the security terms found in this contract, including means for protecting personal privacy and proprietary information;

• Integrity, which means guarding against improper information modification or destruction, and ensuring information non-repudiation and authenticity; and

• Availability, which means ensuring timely and reliable access to and use ofinformation.

b. Provide security for any Contractor systems, and information contained therein, connected to an HTIS network or operated by the Contractor on behalf of HEIS regardless of location. In addition, if new or unanticipated threats or hazards are discovered by either the agency or contractor, or if existing safeguards have ceased to function, the discoverer shall immediately, within one (1) hour or less, bring the situation to the attention of the other party.

c. Adopt and implement the policies, procedures, controls, and standards required by the MIS Information Security Program to ensure the confidentiality, integrity, and availability of government information and government information systems for which the Contractor is responsible under this contract or to which the Contractor may otherwise have access under this contract. Obtain the MIS Information Security Program security requirements, outlined in the MS Information Security and Privacy Policy (IS2P), by contacting the CO/COR or emailing fisma@hhs.gov.

d. Comply with the Privacy Act requirements and tailor FAR clauses as needed..

3) Information Security Categorization. In accordance with FIPS 199 and National Institute of Standards and Technology (NIST) Special Publication (SP) 800-60, Volume II: Appendices to

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Guide for Mapping Types of Information and Information Systems to Security Categories, Appendix C, and based on information provided by the ISSO, CISO, or other security representative, the risk level for each Security Objective and the Overall Risk Level, which is the highest watermark of the three factors (Confidentiality, Integrity, and Availability) of the information or information system are the following:

Confidentiality: [ ] Low [ ] Moderate [ ] High Integrity: [ ] Low [ ] Moderate [ ] High Availability: [ ] Low [ ] Moderate [ ] High Overall Risk Level: [x] Low [ ] Moderate [ ] High

Based on information provided by the ISSO, Privacy Office, system/data owner, or other security or privacy representative, it has been determined that this solicitation/contract involves:

[ ] No PIT [ x ] Yes PIT

Complete this section using the information obtained from the Security and Privacy Checklist in Appendix A, parts A and B. .

Personally Identifiable Information (PII). Per the Office of Management and Budget (OMB) Circular A-130, "PII is information that can be used to distinguish or trace an individual's identity, either alone or when combined with other information that is linked or linkable to a specific individual." Examples of PIT include, but are not limited to the following: social security number, date and place of birth, mother's maiden name, biometric records, etc.

PIT Confidentiality Impact Level has been determined to be: [ x ] Low [ ] Moderate [ ] High

4) Controlled Unclassified Information (CUT). CUT is defined as "infoirnation that laws, regulations, or Government-wide policies require to have safeguarding or dissemination controls, excluding classified information." The Contractor (and/or any subcontractor) must comply with Executive Order 13556, Controlled Unclassified Information, (implemented at 3 CFR, part 2002) when handling CUT. 32 C.F.R. 2002.4(aa) As implemented the term "handling" refers to "...any use of CUT, including but not limited to marking, safeguarding, transporting, disseminating, re-using, and disposing of the information." 81 Fed. Reg. 63323. All sensitive information that has been identified as CUT by a regulation or statute, handled by this solicitation/contract, shall be:

a. marked appropriately;

b. disclosed to authorized personnel on a Need-To-Know basis;

c. protected in accordance with NIST SP 800-53, Security and Privacy Controls for Federal Information Systems and Organizations applicable baseline if handled by a Contractor system operated on behalf of the agency, or NIST SP 800-171, Protecting Controlled Unclassified Information in Nonfederal Information Systems and Organizations if handled by internal Contractor system; and

d. returned to MIS control, destroyed when no longer needed, or held until otherwise directed.

Destruction of infoimation and/or data shall be accomplished in accordance with NIST SP 800-88, Guidelines for Media Sanitization.

5) Protection of Sensitive Information. For security purposes, information is or may be sensitive because it requires security to protect its confidentiality, integrity, and/or availability. The Contractor (and/or any subcontractor) shall protect all government information that is or may be

HHS Security and Privacy Language for Information and Information Technology Procurements v2 Page 3 sensitive in accordance with OMB Memorandum M-06-16, Protection of Sensitive Agency Information by securing it with a FIPS 140-2 validated solution.

See the HHS Standard for the Definition of Sensitive Information, for additional information in defining and protecting sensitive information.

6) Confidentiality and Nondisclosure of Information. Any infoll ation provided to the contractor (and/or any subcontractor) by BITS or collected by the contractor on behalf of

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REIS shall be used only for the purpose of carrying out the provisions of this contract and shall not be disclosed or made known in any manner to any persons except as may be necessary in the performance of the contract. The Contractor assumes responsibility for protection of the confidentiality of Government records and shall ensure that all work performed by its employees and subcontractors shall be under the supervision of the Contractor. Each Contractor employee or any of its subcontractors to whom any HHS records may be made available or disclosed shall be notified in writing by the Contractor that information disclosed to such employee or subcontractor can be used only for that purpose and to the extent authorized herein.

The confidentiality, integrity, and availability of such information shall be protected in accordance with HHS and [0pDiv] policies. Unauthorized disclosure of infaimation will be subject to the 111-1S1[0pDiv] sanction policies and/or governed by the following laws and regulations:

a. 18 U.S.C. 641 (Criminal Code: Public Money, Property or Records);

b. 18 U.S.C. 1905 (Criminal Code: Disclosure of Confidential Information); and

c. 44 U.S.C. Chapter 35, Subchapter I (Paperwork Reduction Act).

7) Contract Documentation. The Contractor shall use provided templates, policies, forms and other agency documents [0pDiv specifi, which documents/forms will be provided to contractod to comply with contract deliverables as appropriate.

See Appendix D for baseline deliverables.

8) Standard for Encryption. The Contractor (and/or any subcontractor) shall:

a. Comply with the HHS Standard for Encryption of Computing Devices and Information to prevent unauthorized access to government information.

b. Encrypt all sensitive federal data and information (i.e., PIT, protected health infoli iation [PHI], proprietary information, etc.) in transit (i.e., email, network connections, etc.) and at rest (i.e., servers, storage devices, mobile devices, backup media, etc.) with FIPS 140-2 validated encryption solution.

c. Secure all devices (i.e.: desktops, laptops, mobile devices, etc.) that store and process government information and ensure devices meet MIS and OpDiv-specific encryption standard requirements. Maintain a complete and current inventory of all laptop computers, desktop computers, and other mobile devices and portable media that store or process

HHS Security and Privacy Language for Information and Information Technology Procurements v2 Page 5 sensitive government information (including PII).

d. Verify that the encryption solutions in use have been validated under the Cryptographic Module Validation Program to confirm compliance with PIPS 140-2. The Contractor shall provide a written copy of the validation documentation to the COR [OpDiv-provided delivery date] .

e. Use the Key Management system on the HITS personal identification verification (PIV) card or establish and use a key recovery mechanism to ensure the ability for authorized personnel to encrypt/decrypt information and recover encryption keys. Encryption keys shall be provided to the COR upon request and at the conclusion of the contract.

9) Contractor Non-Disclosure Agreement (NDA). Each Contractor (and/or any subcontractor) employee having access to non-public government information under this contract shall complete the OpDiv non-disclosure agreement. [OpDiv inserted information/link should be cited here], as applicable. A copy of each signed and witnessed NDA shall be submitted to the Contracting Officer (CO) and/or CO Representative (COR) prior to performing any work under this acquisition.

B. Training

1) Mandatory Training for All Contractor Staff. All Contractor (and/or any subcontractor) employees assigned to work on this contract shall complete the applicable HHS/OpDiv Contractor Information Security Awareness, Privacy, and Records Management training (provided upon contract award) before performing any work under this contract. Thereafter, the employees shall complete [OpDiv-specified] Information Security Awareness, Privacy, and Records Management training at least annually, during the life of this contract. All provided training shall be compliant with HHS training policies.

Role-based Training. All Contractor (and/or any subcontractor) employees with significant security responsibilities (as determined by the program manager) must complete role-based training annually commensurate with their role and responsibilities in accordance withHHS policy and the HHS Role-Based Training (RBT) of Personnel with Signtficant Security Responsibilities Memorandum.

2) Training Records. The Contractor (and/or any subcontractor) shall maintain training records for all its employees working under this contract in accordance with HHS policy. A copy of the training records shall be provided to the CO and/or COR within 30 days after contract award and annually thereafter or upon request.

C. Rules of Behavior

1) The Contractor (and/or any subcontractor) shall ensure that all employees performing on the contract comply with the HEIS Information Technology General Rules of Behavior, and [insert any OpDiv-specific rules, as applicable].

2) All Contractor employees performing on the contract must read and adhere to the Rules of Behavior before accessing Department data or other information, systems, and/or networks that store/process government information, initially at the beginning of the contract and at least annually thereafter, which may be done as part of annual OpDiv Information Security Awareness Training. If the training is provided by the contractor, the signed ROB must be provided as a

HHS Security and Privacy Language for Information and Information Technology Procurements v2 Page 6 separate deliverable to the CO and/or COR per defined timelines above.

D. Incident Response

The Contractor (and/or any subcontractor) shall respond to all alerts/Indicators of Compromise (JO Cs) provided by HHS Computer Security Incident Response Center (CSIRC)/[0pDiv] lIZT teams within 24 hours, whether the response is positive or negative.

FISMA defines an incident as "an occurrence that (1) actually or imminently jeopardizes, without lawful authority, the integrity, confidentiality, or availability of information or an information system; or (2) constitutes a violation or imminent threat of violation of law, security policies, security procedures, or acceptable use policies.. The HHS Policy for IT Security and Privacy Incident Reporting and Response further defines incidents as events involving cybersecurity and privacy threats, such as viruses, malicious user activity, loss of, unauthorized disclosure or destruction of data, and so on.

A privacy breach is a type of incident and is defined by Federal Information Security Modernization Act (FISMA) as the loss of control, compromise, unauthorized disclosure, unauthorized acquisition, or any similar occurrence where (1) a person other than an authorized user accesses or potentially accesses personally identifiable information or (2) an authorized user accesses or potentially accesses personally identifiable information for an other than authorized purpose. The HHS Policy for IT Security and Privacy Incident Reporting and Response further defines a breach as "a suspected or confirmed incident involving PIT".

In the event of a suspected or confirmed incident or breach, the Contractor (and/or any subcontractor) shall:

1) Protect all sensitive information, including any PII created, stored, or transmitted in the performance of this contract so as to avoid a secondary sensitive information incident with FIPS 140-2 validated encryption.

2) NOT notify affected individuals unless so instructed by the Contracting Officer or designated representative. If so instructed by the Contracting Officer or representative, the Contractor shall send [OpDiv] approved notifications to affected individuals [insert OpDiv Specific timeline, process, and format J.

3) Report all suspected and confirmed information security and privacy incidents and breaches to the OpDiv Incident Response Team (IRT) [OpDiv inserted contact information should be cited here] , COR, CO, OpDiv SOP (or his or her designee), and other stakeholders, including incidents involving PII, in any medium or form, including paper, oral, or electronic, as soon as possible and without unreasonable delay, no later than one (1) hour, and consistent with the applicable OpDiv and HHS policy and procedures, NIST standards and guidelines, as well as US-CERT notification guidelines. The types of information required in an incident report must include at a minimum company and point of contact information, contract information, impact classifications/threat vector, and the type of information compromised. In addition, the Contractor shall:

a. cooperate and exchange any infoiniation, as determined by the Agency, necessary to effectively manage or mitigate a suspected or confirmed breach;

b. not include any sensitive information in the subject or body of any reporting e-mail; and

c. encrypt sensitive information in attachments to email, media, etc.

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4) Comply with OMB M-17-12, Preparing for and Responding to a Breach of Personally Identifiable Information HEIS/OpDivREIS and[OpDiv] incident response policies when handling PIT breaches.

5) Provide full access and cooperate on all activities as determined by the Government to ensure an effective incident response, including providing all requested images, log files, and event information to facilitate rapid resolution of sensitive information incidents. This may involve disconnecting the system processing, storing, or transmitting the sensitive infatmation from the Internet or other networks or applying additional security controls. This may also involve physical access to contractor facilities during a breach/incident investigation [0pDiv insert timeline if required] .

E. Position Sensitivity Designations

All Contractor (and/or any subcontractor) employees must obtain a background investigation commensurate with their position sensitivity designation that complies with Parts 1400 and 731 of Title 5, Code of Federal Regulations (CFR). The following position sensitivity designation levels apply to this solicitation/contract:

The requiring activity representative, in conjunction with Personnel Security, shall use the OPM Position Sensitivity Designation automated tool (https://www.opm.gov/investigations/) to determine the sensitivity designation for background investigations. After making those determinations, include all applicable position sensitivity designations..

F. Homeland Security Presidential Directive (HSPD)-12

The Contractor (and/or any subcontractor) and its employees shall comply with Homeland Security Presidential Directive (HSPD)-12, Policy for a Common Identification Standard for Federal Employees and Contractors; OMB M-05-24; FIPS 201, Personal Identity Verification (PIV) of Federal Employees and Contractors; MIS HSPD-12 policy; and Executive Order 13467, Part 1 §1.2.

For additional information, see HSPD-12 policy at: https://www.dhs.goy/homeland-security-presidential-directive-12)

Roster. The Contractor (and/or any subcontractor) shall submit a roster by name, position, e-mail address, phone number and responsibility, of all staff working under this acquisition where the Contractor will develop, have the ability to access, or host and/or maintain a government information system(s). The roster shall be submitted to the COR and/or CO within [0pDiv Specific timeline] of the effective date of this contract. Any revisions to the roster as a result of staffing changes shall be submitted within [0pDiv Specific timeline] of the change. The COR will notify the Contractor of the appropriate level of investigation required for each staff member. [If the OpDiv has an electronic template, include that information here along with a link, if applicable.]

If the employee is filling a new position, the Contractor shall provide a position description and the Government will determine the appropriate suitability level.

G. Contract Initiation and Expiration

1) General Security Requirements. The Contractor (and/or any subcontractor) shall comply with information security and privacy requirements, Enterprise Performance Life Cycle (EPLC) processes, MIS Enterprise Architecture requirements to ensure infonnation is

HHS Security and Privacy Language for Information and Information Technology Procurements v2 Page 8 appropriately protected from initiation to expiration of the contract. All information systems development or enhancement tasks supported by the contractor shall follow the HHS EPLC framework and methodology or [insert OpDiv-specific requirement] and in accordance with the HHS Contract Closeout Guide (2012).

HHS EA requirements may be located here:

https://www.hhs.gov/ocio/ea/documents/proplans.html

2) System Documentation. Contractors (and/or any subcontractors) must follow and adhere to NIST SP 800-64, Security Considerations in the System Development We Cycle, at a minimum, for system development and provide system documentation at designated intervals (specifically, at the expiration of the contract) within the EPLC that require artifact review and approval.

3) Sanitization of Government Files and Information. As part of contract closeout and at expiration of the contract, the Contractor (and/or any subcontractor) shall provide all required documentation [enter OpDiv-specific requirements] to the CO and/or COR to certify that, at the government's direction, all electronic and paper records are appropriately disposed of and all devices and media are sanitized in accordance with NIST SP 800-88, Guidelines for Media Sanitization.

4) Notification. The Contractor (and/or any subcontractor) shall notify the CO and/or COR and system ISSO within [0pDiv-specific timeline] before an employee stops working under this contract.

5) Contractor Responsibilities Upon Physical Completion of the Contract. The contractor (and/or any subcontractors) shall return all government information and IT resources (i.e., government information in non-government-owned systems, media, and backup systems) acquired during the term of this contract to the CO and/or COR. Additionally, the Contractor shall provide a certification that all government information has been properly sanitized and purged from Contractor-owned systems, including backup systems and media used during contract performance, in accordance with MIS and/or [0pDiv] policies.

6) The Contractor (and/or any subcontractor) shall perform and document the actions identified in the [0pDiv] Contractor Employee Separation Checklist [insert links to OpDiv form] when an employee terminates work under this contract within [insert OpDiv-specific timeline] days of the employee's exit from the contract. All documentation shall be made available to the CO and/or COR upon request.

H. Records Management and Retention

The Contractor (and/or any subcontractor) shall maintain all information in accordance with Executive Order 13556 -- Controlled Unclassified Information, National Archives and Records Administration (NARA) records retention policies and schedules and 111-1S/[0pDiv] policies and shall not dispose of any records unless authorized by 111-1S/[0pDiv]

In the event that a contractor (and/or any subcontractor) accidentally disposes of or destroys a record without proper authorization, it shall be documented and reported as an incident in accordance with BITS/[0pDiv] policies.

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1. Requirements for Procurements Involving Privacy Act Records

3.A. Privacy Act

It has been determined that this contract is subject to the Privacy Act of 1974, because this contract provides for the design, development, or operation of a system of records on individuals.

The System of Records Notice (SORN) that is applicable to this contract is: [0pDiv insert SORN number if one exists. If there is no SORN indicate that a SORN will be developed. CC Privacy Office will supply when reviewing procurement request.].

The design, development, or operation work the Contractor is to perform is: [0pDiv insert description of design, development, and/or operation work; see definitions in the FAR at 24.10] - Definitions].

The disposition to be made of the Privacy Act records upon completion of contract performance is: [0pDiv insert records disposition instructions the contractor and any subcontractor must follow upon completion of contract performance. Needs input from Tricia Coffey who is CC Records Management Liaison for CC. ] .

3.B. Privacy Incident Handling and Notification

The Contractor (and/or any subcontractor) shall obtain notification instructions and approval from the Contracting Officer prior to notifying individuals whose PH resided in the Contractor (and/or any subcontractor) IT system at the time of the incident. The method and content of any notification by the Contractor shall be compliant with HHS Privacy Incident Response Team (PIRT) Standard Operating Procedures (SOP) (http://intranet.hhs.gov/it/cybersecurity/docs/incident mgmt/PIRTSOP/pirt sop.pdf ) and NM Guidance as well as coordinated and approved by the ITHS PIRT in consultation with the Contracting Officer, the NIR SAOP (or his or her designee), and/or Computer Security Incident Response Team (CSIRT).

Upon receiving notification and approval from the agency Contracting Officer, the Contractor shall send notifications to affected individuals within [N1H Specific timeline].

(Note: The Contractor (and/or any subcontractor) shall not proceed with any notification to individuals unless the Contracting Officer, in consultation with the HHS PIRT and NM SAOP, has determined in writing that the Contractor notification is appropriate.)

3 .B.1. All determinations related to privacy incidents, including response activities, notifications to affected individuals and/or federal agencies, and related services (e.g., credit monitoring and identity protection) will be made in writing by the Contracting Officer in consultation with the MIS PIRT, NH CIO, and SAOP (or his or her designee) and in compliance with NHS and/or NIH Guidance.

3.B.2. The Contractor (and/or any subcontractor) shall provide full access and cooperation for all activities determined by the Government to be required to ensure an effective incident response, including providing all requested images, log files, and event information to facilitate rapid resolution of sensitive information incidents. Incident response activities determined to be required by the Government may include, but are not limited to, the following:

1. Inspections,

2. Investigations,

3. Forensic reviews, and

4. Data analysis and processing.

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3.C. Privacy Act

3.C.1. Privacy Act Notification (FAR Clause 48 CFR § 52.224-1). The Contractor (and/or any subcontractor) shall comply with FAR Clause 48 CFR § 52.224-1 requirements, which can be located at:

https ://www.acquisition.gov/sites/default/files/current/far/htm1/52_223_226.html

3.C.2. Privacy Act (FAR Clause 48 CFR § 52.224-2). The Contractor (and/or any subcontractor) shall comply with FAR Clause 48 CFR § 52.224-2 requirements, which can be located at:

https://www.acquisition.gov/sites/default/files/current/far/htm1/52_223_226.html

3.C.3. Privacy Act (HHSAR Clause 48 CFR §352.224-70). The Contractor (and/or any subcontractor) shall comply with MBAR Clause 48 CFR §352.224-70 requirements, which can be located at:

https://www.hhs.gov/grants/contracts/contract-policies-regulations/hhsar/part-352-solicitation-provisions-contract-clauses/index.html#352.224-70

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