UW-Madison - IT - Cybersecurity Risk Management Implementation Plan Appendices

Appendix A – University of Wisconsin-Madison Cybersecurity Risk Management Framework

BACKGROUND

Risk is defined as the measure of the extent to which an entity is threatened by a potential circumstance or event, and typically a function of: (i) the adverse impacts that would arise if the circumstance or event occurs; and (ii) the likelihood of occurrence.⁽¹⁾

Cybersecurity risk may be presented from external sources or by individual actions of those working inside the network or information systems. The concept of cybersecurity risk includes operational risk to information and technology assets that have consequences affecting the availability, integrity or confidentiality, of information or information systems. This includes the resulting impact from physical or technical threats and vulnerabilities in networks, computers, programs and data. The data focus includes information flowing from or enabled by connections to digital infrastructure, information systems, or industrial control systems, including but not limited to, information security, supply chain assurance, information assurance, and hardware and software assurance.⁽²⁾

The process described in this policy is a tool used to arrive at an understanding of risk involving information systems. Risk can be modeled as the likelihood of adverse events over a period of time, multiplied by the potential impact of those events. Risk is never reduced to zero. There is always a level of risk that must be accepted as a cost of doing business. Reducing the risk to an acceptable level is also a cost of doing business. Risk ratings are driven by the Risk Assessment Tool which assigns values to threats, vulnerabilities, and likelihood of exploitation to determine risk.

Systems are monitored to assure that the level of cybersecurity risk is maintained at or below an acceptable level. There are policy and procedural safeguards to assure that personal privacy and academic freedom are respected. The content or use of the data is only of interest to the extent that it indicates the presence of a vulnerability or threat, such as incoming data that is part of an attack on university systems, or outgoing data that indicates a system has already been compromised. University or personal data that is stolen by an attacker is no longer private. Scrupulous monitoring helps protect data from unscrupulous use.

INTERNAL AND EXTERNAL THREAT, VULNERABILITY, AND LIKELIHOOD

Threat, vulnerability and likelihood of exploitation are complex and unique to specific business processes and technology. Cybersecurity risk is measurable depending on quantified or classified aspects of the data; characteristics of the information system; the definitions and characteristics of internal or external threat, system or environmental vulnerabilities; and the likelihood that the event or situation may manifest itself within a given application, information system or architecture. Internal threats can be accidental or intentional. Vulnerabilities are normally discovered outside of the information environment and reported by trusted sources and characterized against industry norms. The likelihood an event may take place is dependent on the broader spectrum of people, technology and procedures in place to counter the threat and address the vulnerability.

Table 1 below shows broad definitions of cybersecurity issues and the potential risk level that may be assigned to information systems using the Risk Management Framework.

Table 1: Example Issues and Risk Levels

DESCRIPTION	RISK LEVEL
ROOT-LEVEL INTRUSION: an unauthorized person gained root-level access/privileges on a University computer/information system/network device.	High
USER-LEVEL INTRUSION: an unauthorized person gained user-level privileges on a University computer/information system/network device.	High
ATTEMPTED ACCESS: an unauthorized person specifically targeted a service/vulnerability on a University computer/information system/network device in an attempt to gain unauthorized or increased access/privileges, but was denied access.	Moderate
DENIAL OF SERVICE (DOS): use of a University computer/information system/network was denied due to an overwhelming volume of unauthorized network traffic. DOS activity may be reported as High Risk if a significant segment of the University’s networks are disabled or if designated Critical Infrastructure / Key Resources are taken off-line.	Moderate
POOR SECURITY PRACTICE: a University computer/information system/network was incorrectly configured or a user did not follow established policy. This activity may be rated as Moderate or High if the practice resulted in significant loss of data or denial of service.	Low
SCAN/PROBE: open ports on a University computer/information system/network device were scanned with no DOS or mission impact.	Low
MALICIOUS CODE (MALWARE): hostile code successfully infected a University computer/information system/network device. Unless otherwise directed, only those computers that were infected will be reported as a Moderate Risk incident unless the malware has disabled a complete information system or significant segment of the University’s network.	Moderate
SUSPICIOUS ACTIVITY (INVESTIGATION): any identified suspicious activity. The event will be investigated as Low risk, and either dismissed or categorized as one of the above types of activity.	Low
EXPLAINED ANOMALY: authorized network activity.	None

THE INFORMATION SYSTEM

An information system can be defined as discrete set of information resources organized for the collection, processing, maintenance, use, sharing, dissemination, or disposition of information. Information systems also include specialized systems such as industrial/process controls systems, telephone switching and private branch exchange (PBX) systems, and environmental control systems.⁽³⁾ Each information system should include a security boundary which clearly defines the perimeter of the system and the extent of applicable security controls to be defined and built in to the system. Figure 1 below⁽⁴⁾ shows a simple client-server based system with the security boundary shown in green.

Figure 1: The System Security Boundary

The System Security Plan should address the hardware, software, security controls, and administrative or configuration issues associated with security the system and the data within that boundary. The plan should also describe the interactions with adjacent systems and networks and, where necessary, describe the security controls that protect access and secure the data.

RISK MANAGEMENT FRAMEWORK

The University of Wisconsin-Madison Cybersecurity Risk Management Framework is designed to provide departmental directors and managers, researchers, and information technologists with a tool to determine risk to data and operations of each network or system connected to or serviced by the campus information technology architecture. The Risk Management Framework, also called the RMF, is derived from the National Institute for Standards and Technology Special Publication 800-37 Revision 1, Guide for Applying the Risk Management Framework to Federal Information Systems: A Security Life Cycle Approach and specifically tailored to meet the requirements and culture at the University. This section describes the RMF processes and implementation details and serves as a guide to determining cybersecurity risk to information systems and network architectures. The RMF consists of six steps that guide the development of a system with information security controls built in. Once development is completed, a formal risk assessment and continued operating checks ensure maintenance of defined risk levels. Figure 2 and Table 2 below describe the steps:

Figure 2: The Risk Management Framework

Table 2: Steps within the Risk Management Framework

STEP	ACTIVITY TITLE	DESCRIPTION
PRE	Planning	Conducting discovery with the System Owner to aid in their understanding of the RMF and associated tools and processes. Identification of estimated level of effort, schedule and resources occurs here.
1	Categorize the System	A data driven and collaborative process where the security requirements of the system are defined by the highest classification of data handled by, or stored within, the system or processes. The System Owner must agree with the System Category to move on to the next step.
2	Select Security Controls	Assignment of the administrative, physical and technical controls required to protect the data are drawn from an agreed security controls framework (e.g., NIST 800-53). Alignment with specific compliance programs, (i.e. HIPAA, FERPA, EU GDPR, GLBA, etc.,) is necessary to ensure accuracy. The proper controls are selected by the Risk Analyst in consultation with the System Owner. Controls that are not attainable will be accompanied by a suitable mitigation or explanation from the System Owner will be recorded.
3	Implement and Validate Controls	During design and development, the System Owner and Developers ensure the selected controls are incorporated in the system design, validated to provide the desired protections, and verified as operational. Consulting services from the Office of Cybersecurity are available as resources allow.
4	Risk Assessment	Independent of the development team, the Office of Cybersecurity conducts a documented assessment to test the selected controls. Residual risk is determined with mitigating factors applied. This stage leads to a formal declaration of risk for the system or network.
5	Authorize the System	A final risk review is conducted with a formal declaration of risk provided by the CISO to the responsible Risk Executive who makes the determination whether to (1) operate the system at the defined risk level; (2) further mitigate risk; or (3) decline to allow continued operation.
SYSTEM IS OPERATIONAL
6	Monitor and Mitigate	The System Owner or the Cybersecurity Operations Center should continually assess the operational controls against evolving vulnerability, threat and impact factors. Disruption to operations or loss of data occurs when controls fail, system upgrades occur without proper testing or external factors dictate, determine and implement mitigating controls or return the system to an earlier RMF step. This step is also known as Continuous Diagnostics and Mitigation (CDM).

As shown in Table 3 below, the RMF aligns with the system development life cycle and requires input documentation and information for each step. Output artifacts are produced that are used in planning, development and testing, and certification of risk leading to implementation as shown in the table below.

Table 3: RMF Alignment with System Development Life Cycle

STEP	ACTIVITY TITLE	PROJECT PHASE	INPUT DOCUMENTS AND ACTIVITIES	OUTPUT DOCUMENTS AND ACTIVITIES
1	Categorize the System	Planning and Design	Data definition including Classification FISMA determination from Contract Data description System description from SDLC CIS Benchmarks	Cybersecurity Project Charter System Security Plan (SSP) Questionnaire checklist Data Security Triage Form IT Security Baseline for Research and Academic Computing Template Interview Checklist(s): e.g., FISMA Controls, HIPPA Test Plan, SA Checklist
2	Select Security Controls	Planning and Design	Complete and Validated SSP Questionnaire checklist	Security Controls Inventory
3	Implement and Validate Controls	Develop and Test	Configure Security Controls as determined.	Completed Package Artifacts SSP Topology, Data Flow, System Security Boundary Ports & Protocols Table Security Controls Workbook (Pre-Assessment) Submitted Cybersecurity Risk Acceptance Request Form
4	Risk Assessment	Develop and Test	Provide All Audit Scan (host based scans & application based testing) Completed Security Controls Checklist validated by scanning and manual review Develop and Execute Testing Plans (Artifacts not provided will be created by the Office of Cybersecurity) Step Three Deliverables	Scanning tool, (i.e. Qualys,) generated Risk Assessment Report plus Analyst notes Executed CCI and NIST checklists Updated systems POAM Validated Step Three Artifacts Residual Risk Report
5	Authorize System	Implement	Residual Risk Report Step Four deliverables	Chief Information Security Officer signed Risk Letter plus Risk Executive’s Endorsement/Approval to Operate
6	Mitigate and Monitor (CDM)	Operate	Approved scanning tool Control Validation Plan Step Five deliverables	Provide Monthly Risk Reports & POAM updates Security Control Validation Report

LEVEL OF EFFORT

The time to complete each step within the RMF depends on the data classification, information system size, and technical complexity. Each system will be assigned a Risk Analyst from the Office of Cybersecurity who will consult with and assist the technical teams, developers, system owners, business process owners, IT managers and Risk Executives in navigating the process. Tables 4 and 5 below show a rough estimate of the level of effort for the assigned Risk Analyst for the overall risk assessment effort including all steps in the RMF. Level of effort and time to complete the process should be determined collaboratively at the onset of the project and is the responsibility of the system owner.

The Office of Cybersecurity has limited resources to assist and each engagement would be determined on when assets are available using a “best effort” approach. Table 4 below shows an estimated level of effort based on the type of service needed and the relative size of the information system. This level of effort is contact time with the project only, not calendar hours or days necessary to gather all information, delays due to scheduling challenges, hand off time between reviews, or holiday and weekend hold time. The term “assets” encompasses host terminals, servers, switches, routers, firewalls, intrusion detection or protection systems or peripherals. When defining a system, including all active components that primarily security related is required to properly set the scope of the effort.

Table 4: Estimated Level of Effort

SERVICE	SYSTEM SIZE	# ASSETS	LABOR REQUIRED	LOE HOURS
CONSULTING SUPPORT	Small	1-5	1 Consultant	40
	Medium	6-15	1 Consultant	60
	Large	16-50	1 Consultant	60-80
	Extra Large	50+	1 Consultant 1 Specialist	120+
CONSULTING AND ASSISTANCE IN DEVELOPING SYSTEM SECURITY PLAN AND ARTIFACTS	Small	1-5	1 Consultant	60
	Medium	6-15	1 Consultant	80
	Large	16-30	1 Consultant	160
	Extra Large	30+	1 Consultant 1 Specialist	200+
CONSULTANT SUPPORT LABOR WITH SSP ARTIFACTS AND FULL TESTING SUPPORT	Small	1-5	1 Consultant 1 Specialist	120
	Medium	6-15	2 Consultants	200
	Large	16-50	2 Consultants 1 Specialist	300
	Extra Large	50+	2 Consultant 2-3 Specialists	500+
CYBERSECURITY ARCHITECTURE AND ENGINEERING	Small	1-5	1 Consultant 1 Specialist	Project dependent
	Medium	6-15	2 Consultants
	Large	16-30	2 Consultants 1 Specialist
	Extra Large	30+	1 Consultant 2+ Specialists

The time estimated within each step of the RMF is shown in the table below and reflects a rough estimate of calendar days, weeks or months to process through each step given information is available and testing windows can be scheduled. Time to obtain a Risk Executive Signature is wholly dependent on the organization and the System Owner communications with the Risk Executive.

Table 5: Estaimated Elapsed Time within each Step of the RMF

STEP WITHIN RMP	SYSTEM SIZE	ESTIMATED HOURS OR DAYS WITHIN EACH STEP
PLANNING	Small	2 weeks
	Medium	2 weeks
	large	2-3 weeks
	Extra Large	2-3 weeks
STEP 1: CATEGORIZE THE SYSTEM	Small	1 day
	Medium	1 day
	large	1 day
	Extra Large	2 days
STEP 2: SELECT SECURITY CONTROLS	Small	1 day
	Medium	1 day
	large	2 days
	Extra Large	1 week
STEP 3: IMPLEMENT AND VALIDATE CONTROLS	Small	System Owner and Project Team dependent
	Medium
	large
	Extra Large
STEP 4: RISK ASSESSMENT	Small	2 days (depending on test duration needed)
	Medium	<5 days (depending on test duration needed)
	large	1.5-2 weeks (depending on test duration needed)
	Extra Large	>2 weeks (depending on test duration needed)
STEP 5: AUTHORIZE THE SYSTEM (PRESENTATION AND CISO SIGNATURE)	Small	<1 day
	Medium	1 day
	large	<2 days
	Extra Large	2 days
STEP 5: AUTHORIZE THE SYSTEM (RISK EXECUTIVE SIGNATURE)	Small	<1 day
	Medium	1 day
	large	<2 days
	Extra Large	2 days

A full description of each service and activities that take place in each step of the RMF along with information on the related cost is available upon request from the Office of Cybersecurity.

SECURITY CONTROL INHERITANCE

For most information systems and applications, there are security controls that can be inherited from the surrounding infrastructure or adjacent business processes or systems within the architecture. System Owners and Risk Executives should consider a security control as “inheritable” if it is a verified security asset. Much like an inheritance receive from the death of a relative, it’s not real until it has been verified to exist and is functioning.

Information Systems “inherit” controls from an architecture or program like a child inherits heirlooms, property or money from a parent. System owners can allow “inheritance” of a security control to another architecture much as the deceased addressed the disposition of their earthly items in their Last Will and Testament. When an information system allows a control to be “inherited” and used by another system or architecture, the “parent” System Owner is responsible for keeping the control functioning – including making available to the “child” System Owner a record of periodic verification of that control.

Finally, the inherited control has to be appropriate for the system or architecture. For example, inheriting multi-factor authenticator management from the current UW System Human Resources System (HRS) which is using Symantec Multi-factor Authentication (MFA) and applying that control to a research data warehouse system where we want to have Duo MFA in place is, by rote, a control you cannot inherit where inheriting the availability of backup power supplied to a data center can cover a broad group of systems if housed within that data center.

Inherited security controls should be clearly marked within the Risk Assessment Tool and the Plan of Action and Milestones for the information system.

CONTACT

Questions and comments to this document can be directed to the Office of Cybersecurity at cybersecurity@cio.wisc.edu.

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Appendix B – Initial List of Risk Executives

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Appendix C – Terms, Definitions and Acronyms

TERMS AND DEFINITIONS

The terms and definitions shown below are provided to clarify specific characteristics of cybersecurity articulated within this document. Reference to source documents are provided as necessary to ensure complete understanding

.

Application

A software program hosted by an information system. (NIST SP 800-37r1, Appendix B)

Availability

Ensuring timely and reliable access to and use of information. (44 U.S.C., Sec. 3542)

Authorization (to operate)

The official management decision given by the Risk Executive to authorize operation of an information system and to explicitly accept the risk to organizational operations (including mission, functions, image, or reputation), organizational assets, individuals, and other organizations, based on the implementation of an agreed-upon set of security controls. (NIST SP 800-37r1, Appendix B, Adapted)

Confidentiality

Preserving authorized restrictions on information access and disclosure, including means for protecting personal privacy and proprietary information. (44 U.S.C., Sec. 3542)

Cybersecurity

The ability to protect or defend the use of cyberspace from cyber-attacks (CNSS 4009). Derived from the term “cybernetics” which is the scientific study of communication and control processes in biological, mechanical, and electronic systems and originated from Greek kubernan meaning to steer or control (OED).

Data Governance

As defined by the implementation of the UW–Madison data management framework, (in progress). For more information contact itpolicy@cio.wisc.edu.

Information Category

As defined in National Institute of Standards and Technology Special Publication 800-60 (NIST SP 800-60 rev 1), Guide for Mapping Types of Information and Information Systems to Security Categories; Information is categorized according to its information type. An information type is a specific category of information (e.g., privacy, medical, proprietary, financial, investigative, contractor sensitive, security management) defined by an organization or, in some instances, by a specific law, Executive Order, directive, policy, or regulation. UW–Madison information categories are represented on Page 6 of the Introduction to this document.

Information Classification

In the context of information security, is the classification of data based on its level of sensitivity and the impact to the University should that data be disclosed, altered or destroyed without authorization. The classification of data helps determine what baseline security controls are appropriate for that data.

Information System

A discrete set of information resources organized for the collection, processing, maintenance, use, sharing, dissemination, or disposition of information. (See 44 U.S.C., Sec. 3502; OMB Circular A-130, Appendix III)

Information Security

The protection of information and information systems from unauthorized access, use, disclosure, disruption, modification, or destruction in order to provide confidentiality, integrity, and availability. (44 U.S.C., Sec. 3542)

Integrity

Guarding against improper information modification or destruction, and includes ensuring information non-repudiation and authenticity. (44 U.S.C., Sec. 3542)

Plan of Actions and Milestones (POAM)

A document that identifies tasks needing to be accomplished. It details resources required to accomplish the elements of the plan, any milestones in meeting the tasks, and scheduled completion dates for the milestones. (OMB Memorandum 02-01)

Risk

A measure of the extent to which an entity is threatened by a potential circumstance or event, and typically a function of: (i) the adverse impacts that would arise if the circumstance or event occurs; and (ii) the likelihood of occurrence. (FIPS 200, Adapted)

Risk Analyst

Individual from the Office of Cybersecurity assigned to help capture and refine information security requirements and ensure their integration into information technology component products and information systems through purposeful security design or configuration. (NIST SP 800-37r1, Appendix B, Adapted)

Risk Assessment

The process of identifying risks to organizational operations (including mission, functions, image, reputation), organizational assets, individuals, and other organizations, resulting from the operation of an information system. (NIST SP 800-37r1, Appendix B, Adapted)

Risk Executive

The Risk Executive should be an executive or director, (e.g., Dean or their appointee, department chair, director of a research lab, etc.,) within the academic / functional unit, or in the line of authority above that unit. The Risk Executive must have the authority to accept the risk of operating the system on behalf of the institution and should be in the unit who will ultimately be responsible for paying for a breach (i.e., Dean or their appointee, department, research lab, etc.) (Cybersecurity Risk Management Implementation Plan)

Risk Executive (Function)

An individual or group within an organization that helps to ensure that: (i) security risk-related considerations for individual information systems, to include the authorization decisions, are viewed from an organization-wide perspective with regard to the overall strategic goals and objectives of the organization in carrying out its missions and business functions; and (ii) managing information system-related security risks is consistent across the organization, reflects organizational risk tolerance, and is considered along with other organizational risks affecting mission/business success.

Risk Management

The process of managing risks to organizational operations (including mission, functions, image, reputation), organizational assets, individuals, other organizations, and the Nation, resulting from the operation of an information system, and includes: (i) the conduct of a risk assessment; (ii) the implementation of a risk mitigation strategy; and (iii) employment of techniques and procedures for the continuous monitoring of the security state of the information system. (FIPS 200, Adapted)

Risk Register

A database managed by the Office of Cybersecurity that contains records for each Information System to which the Risk Management Framework is applied.

Security Category

“The characterization of information or an information system based on an assessment of the potential impact that a loss of confidentiality, integrity, or availability of such information or information system would have on organizational operations, organizational assets, or individuals.” (FIPS 199, Appendix A, p.8)

Security Controls

The management, operational, and technical controls (i.e., safeguards or countermeasures) prescribed for an information system to protect the confidentiality, integrity, and availability of the system and its information. (FIPS 199)

Security Control Inheritance

A situation in which an information system or application receives protection from security controls (or portions of security controls) that are developed, implemented, assessed, authorized, and monitored by entities other than those responsible for the system or application; entities either internal or external to the organization where the system or application resides. (NIST SP 800-37r1, Appendix B)

System Owner

Official responsible for the overall procurement, development, integration, modification, or operation and maintenance of an information system. (NIST SP 800-37r1, Appendix B)

System Security Plan

Formal document that provides an overview of the security requirements for an information system and describes the security controls in place or planned for meeting those requirements. (NIST SP 800-37r1, Appendix B; See: NIST SP 800-18)

Threat

Any circumstance or event with the potential to adversely impact organizational operations (including mission, functions, image, or reputation), organizational assets, individuals, or other organizations through an information system via unauthorized access, destruction, disclosure, modification of information, and/or denial of service. (NIST SP 800-37r1, Appendix B, Adapted)

Threat Source

The intent and method targeted at the intentional exploitation of a vulnerability or a situation and method that may accidentally trigger a vulnerability. Synonymous with threat agent. (NIST SP 800-37r1, Appendix B)

Vulnerability

Weakness in an information system, system security procedures, internal controls, or implementation that could be exploited or triggered by a threat source. (NIST SP 800-37r1, Appendix B)

ACRONYMS AND ABBREVIATIONS

Table 1 below provides the long title associated with acronyms or abbreviations used in this document.

Table 1: Acronyms and Abbreviations

Acronym or Abbreviation	Long Title
D-CISO	Deputy Chief Information Security Officer
CDM	Continuous Diagnostics and Mitigation
CIO	Chief Information Officer
CISO	Chief Information Security Officer
DoIT	Division of Information Technology
FERPA	Family Educational Rights and Privacy Act of 1974
HCC	Health Care Component (of UW–Madison)
HIPAA	Health Insurance Portability and Accountability Act of 1996
HITECH	Health Information Technology for Economic and Clinical Health Act
HRS	Human Resource System
IRB	Institutional Review Board
ITC	Information Technology Committee
NIST	National Institute for Standards and Technology
NIST SP	NIST Special Publication
PCI-DSS	Payment Card Industry Data Security Standard
PHI	Protected Health Information
PII	Personally Identifiable Information
PAT	Policy Planning and Analysis Team
POAM	Plan of Actions and Milestones
RMF	Risk Management Framework
SDLC	System Development Life Cycle
SETA	Security Education, Training, and Awareness
SFS	Shared Financial System
UW–Madison	University of Wisconsin–Madison
UW–MIST	UW–Madison Information Security Team
UWSA	University of Wisconsin System Administration
VCFA	Vice Chancellor for Finance and Administration
VP IT	Vice Provost for Information Technology