Incident Communication and Regulatory Compliance Policy (RES-POL-004)

1. Objective

The objective of this policy is to establish comprehensive requirements for incident response procedures, communication protocols, and regulatory compliance activities during security incidents at [Company Name]. This policy ensures that security incidents are handled through standardized response procedures, appropriate stakeholders are notified in a timely manner, and all regulatory and legal obligations are met throughout the incident lifecycle. By implementing structured communication and compliance processes, [Company Name] maintains transparency with stakeholders, meets regulatory notification requirements, and preserves legal and regulatory standing while effectively managing incident response activities in coordination with the Incident Response Framework & Team Management Policy (RES-POL-001).

2. Scope

This policy applies to all [Company Name] workforce members, contractors, third parties, and business associates involved in incident response activities, stakeholder communications, or regulatory compliance processes. It encompasses all types of security incidents including data breaches, system compromises, malware infections, and other events that require formal response procedures. This policy covers communication with internal stakeholders, external parties including customers and vendors, regulatory bodies, law enforcement, and the media, as well as all regulatory notification and compliance requirements under HIPAA, HITECH, state data breach laws, and other applicable regulations.

3. Policy

[Company Name] shall implement comprehensive incident response procedures and communication protocols that ensure effective incident management, appropriate stakeholder notification, and full compliance with all regulatory and legal requirements throughout the incident response lifecycle.

3.1 Incident Response Procedures

Standardized procedures shall be followed for responding to different types of security incidents once they have been detected and triaged through the Security Event Detection and Monitoring Policy (RES-POL-003).

3.1.1 Initial Response Procedures

• Incident Verification and Classification:
  • Confirm that a security incident has actually occurred based on detection and monitoring activities
  • Gather comprehensive information about the scope, impact, and affected systems
  • Classify the incident according to established severity criteria from RES-POL-001
  • Activate appropriate incident response procedures based on classification
  • Notify relevant incident response team members as defined in RES-POL-001
• Evidence Preservation and Documentation:
  • Preserve all relevant digital and physical evidence in its original state
  • Document all actions taken, decisions made, and timeline of events
  • Maintain strict chain of custody procedures for all evidence
  • Take system snapshots or forensic images before making changes
  • Collect network traffic captures, log files, and other relevant artifacts
  • Establish secure evidence repository with access controls and audit logging

3.1.2 Containment Procedures

• Short-term Containment:
  • Isolate affected systems from the network to prevent lateral movement
  • Disable compromised user accounts and force password changes
  • Block malicious IP addresses, domains, and communication channels
  • Implement temporary firewall rules and access controls to prevent spread
  • Preserve system state and evidence while implementing containment measures
  • Coordinate containment activities with system owners and administrators
• Long-term Containment:
  • Rebuild compromised systems from known clean backups or baseline images
  • Implement enhanced monitoring and logging on affected and related systems
  • Apply all relevant security patches and configuration hardening measures
  • Conduct comprehensive security validation before system restoration
  • Monitor for signs of persistent compromise or reinfection
  • Update security controls and detection capabilities based on incident findings

3.1.3 Eradication and Recovery Procedures

• Threat Eradication:
  • Remove all malware, malicious artifacts, and unauthorized access from systems
  • Close security vulnerabilities and configuration weaknesses that enabled the incident
  • Improve security controls and detection capabilities to prevent recurrence
  • Validate that all traces of compromise have been completely eliminated
  • Conduct comprehensive security assessment of all remediated systems
  • Document all eradication activities and validation procedures
• System Recovery and Restoration:
  • Restore systems and data from verified clean backups
  • Implement additional security monitoring and protective controls
  • Gradually restore full system functionality with continuous monitoring
  • Conduct comprehensive user acceptance testing and functionality validation
  • Monitor systems continuously for signs of compromise or instability
  • Coordinate recovery activities with business units and stakeholders

3.2 Regulatory and Legal Compliance

Incident response procedures shall ensure compliance with all applicable legal and regulatory mandates throughout the incident lifecycle.

3.2.1 HIPAA Breach Notification Requirements

• Breach Assessment and Determination:
  • Conduct formal assessment to determine whether incident constitutes a HIPAA breach
  • Evaluate the probability that electronic Protected Health Information (ePHI) has been compromised
  • Assess the risk of harm to affected individuals based on incident specifics
  • Document the breach assessment decision, rationale, and supporting evidence
  • Coordinate assessment with Privacy Officer, Legal Counsel, and incident response team
• HIPAA Notification Timelines and Requirements:
  • Individual Notification: Within 60 days of breach discovery for all affected individuals
  • HHS Notification: Within 60 days of breach discovery through HHS breach notification portal
  • Media Notification: Within 60 days if breach affects 500 or more individuals in a state/jurisdiction
  • Immediate HHS Notification: Within 60 days if breach affects 500 or more individuals nationwide
  • Annual Summary: Submit summary of smaller breaches (less than 500 individuals) annually to HHS
• Notification Content Requirements:
  • Description of what happened and when the breach occurred
  • Types of information that were involved in the breach
  • Steps individuals should take to protect themselves from potential harm
  • What [Company Name] is doing to investigate, mitigate, and prevent future occurrences
  • Contact information for individuals to ask questions or get additional information

3.2.2 Additional Regulatory and Legal Requirements

• State Data Breach Notification Laws:
  • Identify applicable state notification requirements based on affected individual residency
  • Comply with varying state timelines, notification methods, and content requirements
  • Coordinate notifications with state attorneys general as required by state law
  • Maintain documentation of all state notification activities and compliance
• Federal and Industry-Specific Requirements:
  • SEC Notification: Material cybersecurity incidents for public companies (if applicable)
  • Financial Industry Notifications: Banking, credit, or financial service requirements (if applicable)
  • Professional Licensing Board Notifications: Healthcare or professional service requirements (if applicable)
  • Insurance Carrier Notification: Cyber insurance claim procedures and requirements
  • Law Enforcement Coordination: FBI, Secret Service, or other federal agency reporting as appropriate

3.2.3 Legal Hold and Evidence Management

• Litigation Hold Procedures:
  • Implement litigation hold for all relevant documents and electronic information
  • Preserve all incident-related communications, logs, and documentation
  • Coordinate with Legal Counsel on scope and duration of preservation requirements
  • Train incident response team on legal hold obligations and procedures
  • Document all preservation activities and ensure compliance with legal requirements
• Law Enforcement Coordination:
  • Coordinate with appropriate law enforcement agencies for criminal incidents
  • Provide evidence and support for law enforcement investigations
  • Balance operational recovery needs with law enforcement evidence preservation
  • Maintain chain of custody for evidence provided to law enforcement
  • Document all law enforcement interactions and coordination activities

3.3 Communication and Coordination

Effective communication shall be maintained with all stakeholders throughout the incident response process.

3.3.1 Internal Communications

• Executive Leadership Reporting:
  • Immediate notification to CEO and Executive Leadership for Critical and High severity incidents
  • Regular status updates throughout incident response with timeline and impact assessment
  • Final incident report with comprehensive analysis, lessons learned, and recommendations
  • Board of Directors notification for significant incidents affecting organizational reputation or compliance
  • Coordination with legal counsel on all executive communications
• Workforce Communications:
  • Information sharing on need-to-know basis to protect investigation integrity
  • General security awareness messages as appropriate to enhance organizational security posture
  • Post-incident training and awareness updates incorporating lessons learned
  • Recognition programs for effective incident reporting and response activities
  • Clear communication channels for questions and concerns from workforce members

3.3.2 External Communications

• Customer and Client Communications:
  • Timely notification of customers and clients potentially affected by security incidents
  • Clear, accurate explanation of incident impact and potential risks
  • Regular updates on investigation progress and remediation efforts
  • Dedicated communication channels and contact information for questions and concerns
  • Coordination with customer success and account management teams
• Vendor and Business Associate Communications:
  • Notification of business associates and vendors as required by contracts and regulations
  • Coordination with third-party service providers for incident response and recovery activities
  • Information sharing with industry partners and threat intelligence communities
  • Coordination with insurance carriers and coverage providers for claim processing
  • Vendor assistance coordination for specialized incident response services

3.3.3 Media and Public Communications

• Media Relations:
  • Designation of authorized spokesperson for all media interactions
  • Coordination with public relations team and external communications specialists
  • Preparation of consistent messaging and talking points for media inquiries
  • Proactive media outreach for significant incidents requiring public notification
  • Monitoring of media coverage and social media for accuracy and sentiment
• Regulatory Communications:
  • Formal notifications to regulatory bodies as required by law and regulation
  • Coordination with regulatory affairs team for ongoing compliance activities
  • Response to regulatory inquiries and investigation requests
  • Documentation of all regulatory communications and interactions
  • Legal counsel review of all regulatory communications before submission

3.4 Post-Incident Activities and Lessons Learned

Comprehensive post-incident activities shall ensure organizational learning, process improvement, and enhanced security posture.

3.4.1 Incident Documentation and Reporting

• Comprehensive Incident Report Contents:
  • Complete chronological timeline of incident detection, response, and recovery activities
  • Detailed root cause analysis and identification of all contributing factors
  • Comprehensive impact assessment including affected systems, data, and stakeholders
  • Evaluation of response effectiveness and identification of lessons learned
  • Specific recommendations for security improvements and process enhancements
  • Financial impact assessment and cost analysis of incident and response

3.4.2 Lessons Learned and Continuous Improvement

• Post-Incident Review Process:
  • Formal lessons learned meeting within [Timeframe, e.g., 2 weeks] of incident closure
  • Analysis of response effectiveness with focus on communication and compliance activities
  • Review of incident response plan adequacy and identification of needed updates
  • Evaluation of team performance and identification of additional training requirements
  • Assessment of detection capabilities and monitoring effectiveness for future improvements
• Process and Security Improvement Implementation:
  • Update incident response procedures based on lessons learned and best practices
  • Implement additional security controls to prevent similar incidents
  • Enhance monitoring and detection capabilities based on incident findings
  • Improve training and awareness programs incorporating new threats and techniques
  • Update business continuity and disaster recovery plans based on incident impact
  • Share lessons learned with industry peers and professional communities

4. Standards Compliance

See Annex: Control Mapping

5. Definitions

See Annex: Glossary

6. Responsibilities

Role	Responsibility
Incident Commander	Lead incident response activities, coordinate communication efforts, make critical response decisions, and ensure compliance with all regulatory requirements.
Privacy Officer	Assess HIPAA breach requirements, coordinate breach notifications, manage patient communications, ensure privacy compliance, and oversee regulatory notification activities.
Legal Counsel	Provide legal guidance throughout incident response, coordinate law enforcement relations, manage litigation holds, ensure regulatory compliance, and review external communications.
Communications Team	Manage internal and external communications, coordinate media relations, support crisis communications, develop messaging, and maintain stakeholder relationships.
Security Officer	Oversee incident response procedures, ensure policy compliance, coordinate with regulatory bodies, manage incident documentation, and drive continuous improvement initiatives.
Compliance Team	Ensure regulatory notification compliance, coordinate with regulatory affairs, manage compliance documentation, support audit activities, and maintain regulatory relationships.
IT Security Team	Implement technical response procedures, conduct forensic analysis, coordinate system recovery, preserve evidence integrity, and support compliance activities.
Executive Leadership	Provide strategic guidance and resources, approve major response decisions, coordinate with board and stakeholders, and ensure organizational commitment to improvement.
All Workforce Members	Follow incident response procedures, support communication efforts, cooperate with investigations, maintain confidentiality, and participate in post-incident improvement activities.