Department: UW School of Dentistry IT Services
Policy Number: SP-02
Effective Date: 2/25/2016
Revision Date: 11/17/2023
Reviewer: Alex Agpalo, Compliance & Training Committee
This policy defines the requirements for protecting UW School of computerized devices and information systems in accordance with regulatory requirement and University policy.
This policy applies to all computing devices and systems that use, access, transmit, or store UW School of Dentistry electronic data. All UW School of Dentistry computing devices must also meet the University of Washington Administrative Policy Statements.
Computing devices include but are not limited to; desktop and laptop computers, smart phones, tablet PCs, servers, and applications.
A computing system is any computing device or collection of devices that is used for UW School of Dentistry business.
This policy applies to all UW School of Dentistry workforce members.
All computing devices and systems used to conduct UW School of Dentistry business must meet the requirements below pertaining to the use, management, maintenance, and security of the device(s) in addition to all applicable University of Washington Administrative policies.
Planning and Acceptance (PA)
Prior to purchasing a computing device or system; the security aspects must be evaluated and documented, including where the device will be housed, if it will be connected to a UW School of Dentistry network, who will have access to the data, whether or not it will access, transmit, or store restricted or confidential data.
Requirement: (PA-1) Prior to purchasing a computing device that will be classified as confidential, system characterization and the proposed security controls must be documented according to the System Security Process Standard. Documentation must be maintained by the system owner and system operator.
Purchasing Computing Devices (PCD)
All computing devices within UW School of Dentistry must have the appropriate documentation in place prior to purchase if the device(s) will be supported by the vendor or a non-UW School of Dentistry workforce member.
Requirement: (PCD-1) Any computing device or system requiring vendor support that transmits, processes, or stores Protected Health Information (PHI) must have a Business Associate Agreement in place prior to the purchase.
Requirement: (PCD-2) If a vendor or other non-UW School of Dentistry workforce will have access to Restricted or Confidential data, including but not limited to PHI, on a computing device or system; a Data Security Addendum must be signed by those non-UW School of Dentistry workforce prior to purchasing of the system.
Security Agreements (SA)
Security agreements are any legal document, signed by a UW School of Dentistry workforce member who has been granted signing authority, that pertains to a computing device or system.
Requirement: (SA-1) Appropriate security agreements must be signed by all third party vendors and authorized UW School of Dentistry personnel prior to the purchase or lease of a computing device or system.
Personally Owned Computing Devices (POCD)
UW School of Dentistry recognizes the need for some workforce members to use personally owned devices to conduct business operations.
Requirement: (POCD-1) Any computing device that is personally owned by a UW School of Dentistry workforce member, who is using it for UW School of Dentistry business operations, and has it connected to a UW School of Dentistry network must insure that the computing device meets the same security policy requirements any UW School of Dentistry owned device must meet.
System Criticality (SC)
The criticality of a system helps to define its impact to business operations, how the business continuity plan should be structured, and provides users of the computing device or system expectations for performance.
Requirement: (SC-1) All computing devices and systems must have a criticality assigned based on its importance to UW School of Dentistry business operations.
Physical Security (PS)
UW School of Dentistry has many publicly accessible areas. Access to computing systems must be restricted based on the system’s criticality.
Requirement: (PS-1) All computing devices must have physical security controls in place commensurate with their System Criticality and value. No computing device or system with electronic data classified as Restricted or Confidential can be stored or hosted in a public area.
Requirement: (PS-2) All computing devices and systems must have controls in place to mitigate theft and unauthorized access.
Requirement: (PS-3) All computing devices must have environmental controls in place to mitigate damage caused by environmental threats such as moisture, fire, dust, and temperature.
Requirement: (PS-4) All system owners must keep a maintenance log that records who accessed the hardware and for what purpose. Maintenance logs must be retained for a minimum of two months.
System Ownership (SO)
Collections of computing devices are more complex to manage and maintain than a single device. System owners are responsible for all aspects of the system.
Requirement: (SO-1) All computing systems in use at UW School of Dentistry must have a system owner designated according to APS 2.4 – Information Security and Privacy Roles, Responsibilities, and Definitions.
Requirement: (SO-2) System Owners must be current UW School of Dentistry workforce members.
User Access (UA)
User Access must be restricted using the principle of least privilege, and have the necessary authorization and authentication methods to restrict data access to only authorized users.
Requirement: (UA-1) All computing devices must have an authorization and authentication mechanism that meets the requirements of the classification of that system’s data.
Requirement: (UA-2) All computing devices must allow users to change their passwords at least 120 days. The system owner must enforce password rotation requirements and lock a user account if the password is allowed to expire.
Requirement: (UA-3) Workforce members will only be given access to data and resources they need to complete their assigned work.
Requirement: (UA-4) For workforce members terminated with cause, a process must be in place to remove user access immediately.
Hardware Security (HS)
Requirement: (HS-1) All computing devices and systems must have a maintenance schedule implemented to insure the computing device or system is in proper running order to meet its business purpose.
Software Security (SS)
Requirement: (SS-1) All software used on UW School of Dentistry computing device and systems must be kept up to date, evaluated for security vulnerabilities, and be supported either by the vendor or designated UW School of Dentistry workforce.
Requirement:(SS-2) Off-the-shelf software must be updated regularly.
Requirement: (SS-3) Custom software must be assessed for vulnerabilities before being put into production.
Requirement: (SS-4) Unsupported software must not be installed on any UW School of Dentistry networked computing device.
Network Security and Protection Against Malicious code (NSMC)
All UW School of Dentistry computing devices must be protected from malicious code and unauthorized access using the appropriate methodologies for the device or system.
Requirement: (NSMC-1) All UW School of Dentistry computing devices connected to any University of Washington network must have security controls in place to prevent unauthorized access from network or code based attack vectors.
Computing Device Disposal (CDD)
Many UW School of Dentistry computing devices are resold to the general public to gather any residual value left in the computing device.
Requirement: (CDD-1) All computing devices must have all information rendered inaccessible in accordance with the Data Disposal Standard prior to being transferred to an authorized University department for disposal.
Event Logging (EL)
Depending on the type of computing device or system there are different types of event logs; not all computing devices will have event logging capabilities.
Requirement: (EL-1) All computing devices with event logging capabilities must have event logging enabled.
Requirement: (EL-2) All system administrators are responsible for maintaining and reviewing event logs.
Requirement: (EL-3) Event logs must be retained according to the system’s data classification.
Computing System Monitoring (CSM)
UW School of Dentistry networks are constantly under attack by external sources. All systems must be monitored for signs of intrusion and/or unauthorized access.
Requirement: (CSM-1) All computing devices and systems regardless of criticality must be monitored for unauthorized access.
Business Continuity (BC)
All computing devices and systems at UW School of Dentistry play a role in business operations. It is very important for system owners and users of the computing devices and systems to understand that role.
Requirement: (BC-1) All computing devices and systems must have a written business continuity plan that outlines how business operations will continue in the event that the computing device or system fails.
Requirement: (BC-2) The business continuity plan must contain sections addressing disaster recovery, emergency mode operations, testing and revision procedures, and applications and data criticality analysis.
System Level Risk Assessment (SLRA)
Risk Assessments are needed to identify gaps in security control coverage. Performing risk assessments on systems will identify vulnerabilities that can be mitigated by adding security controls.
Requirement: (SLRA-1) All computing systems must have a written risk assessment documented.
Requirement: (SLRA-2) System Level Risk Assessments must be updated at least annually or when there are changes to the system or the threat environment.
Requirement: (SLRA-3) All risks identified, as a high classification must be mitigated. If mitigation is not possible it must be reported to UW School of Dentistry executive management.
Incident Response (IR)
When a computing device is involved in an incident it is extremely important to follow
APS 2.5 – Information Security and Privacy Incident Management Policy, preserve the evidence, contain the damage, and recover business operations.
Requirement: (IR-1) All incidents must be reported to the office designated in the UW Incident Management Policy as soon as they are discovered or suspected.
Requirement: (IR-2) All incidents will follow the process outlined in the UW Incident Management Policy and the procedures outlined in the IRP (Incident Response Plan).
This policy was signed and approved by:
André V. Ritter, DDS, MS, MBA, PhD Dean
University of Washington School of Dentistry