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UTHSCSA Confidential Information Security Third-Party Assessment Survey Page 1 of 10

NOTE: Prior to finalising business agreements involving confidential data, this completed form should be sent to
Information Security Management for review concerning the security of information with respect to
legal or regulatory compliance and industry standard best practices.

Third-Party Provider Name:______________________________________________________ Date: __________________

Address : __________________________________________________________ Website: _____________________________
IT Security Contact: ________________________________Email:_________________________ Phone: __________________
Location of Data Center: ____________________________Contact:_________________________Phone: _________________
Location of Recovery Center: ________________________Contact:_________________________Phone: _________________

Description of Service/Product:____________________________________________________________________________

Users of the System:_____________________________________________________________________________________

Technical Description (client, agent, SSL, FTP transmission, hosted website, ASP, etc.): _______________________________
Describe Pertinent Outsourced/Contracted Service Arrangements: (such as: onsite support, remote support,
temporary access, database management, etc.)__________________________________________________________________

(mark a "1" in all boxes applicable for this relationship)

Transmit Stores Data Type (if needed, refer to definitions worksheet tab)
or Access Offsite Risk Comments
High Protected Health Information (PHI)
High Social Insurance Numbers (SIN)
High Payment Card Information
High Sensitive Digital Research Data
High Physical Plant Detail
High Institution Mission Critical Information
Medium Business Critical Information
Medium Intellectual Property
Medium Other Sensitive Information
Low Public Information

Answer: 0 = Not Applicable, based on service provided

1 = Yes
2 = Partially
3 = No

Comments: are optional, but may be used to explain answers.

Answer Comments A. Company Information. The vendor: Comments
1. Will accommodate an onsite visit for a security audit within 24 hours notice.
2. Will store all confidential data within country - incl. backups.
3. Maintains an audit log for the location of all Company confidential data and their
backups, to identify where it is located at any point in time, in order to address
privacy laws for storage within Country
4. Will not access Company confidential data from outside of Country.
UTHSCSA Confidential Information Security Third-Party Assessment Survey Page 2 of 10

0 Total Company Controls

Answer Comments B. Polices, Standards and Procedures. The vendor: Comments
1. Has formal written Information Security Policies.
2. Will provide copies of the Information Security Policies.
3. Can provide results of a third-party external Information Security assessment
conducted within the past 2 years (SAS-70, pen. test, vulnerability assess., etc.).
4. Maintains incident response procedures.
5. Has a policy to protect client information against unauthorised access; whether
stored, printed, spoken or transmitted.
6. Has a policy that prohibits sharing of individual accounts and passwords.
7. Has a policy that implements the following Information Security concepts: need to
know, least privilege and checks and balances.
8. Requires system administrators to be educated and qualified.
9. Implements AAA (Authentication, Authorisation, Accounting) for all users.
10. Performs background checks for individuals handling confidential information.
11. Has termination or job transfer procedures that immediately protect
unauthorised access to information.
12. Provides customer support with escalation procedures.
13. Has documented change control processes.
14. Requires contractors, subcontractors, vendors, outsourcing ventures, or other
external third-party contracts to comply with policies and customer agreements.
15. Has a policy that implements provincial regulatory requirements.
16. Maintains a routine user Information Security awareness program.
17. Has a formal routine Information Security risk management program for risk
assessments and risk management.
0 Total Policy Controls
Answer Comments C. Architecture. The vendor: Comments
1. Will provide a network topology diagram/design.
2. Implements network firewall protection.
3. Implements web application firewall protection.
4. Implements host firewall protection.
5. Maintains routers and ACLs.
6. Provides network redundancy.
7. Has IDS/IPS technology implemented.
8. Uses DMZ architecture for Internet systems.
9. Adheres to the practice that web applications, which ’face’ the Internet, are on a
server different from the one that contains the database.
10. Uses enterprise virus protection on all systems.
11. Follows a program of enterprise patch management.
12. Provides dedicated customer servers to segregate UBC data from other
customer data. If not then how is this accomplished in a secure virtual or segmented

13. Implements controls to restrict access to Company data from other customers.
14. Ensures that remote access is only possible over secure connections.
15. Uses separate physical and logical development, test and production
environments and databases.
16. Secures development and test environments using, at a minimum, equivalent
security controls as the production environment.
17. Will provide the architectural software solution design with security controls.
18. Has managed, secure access points on its wireless network.
0 Total Architecture Controls
Answer Comments D. Configurations. The vendor: Comments
1. Has password-protected screen savers that activate automatically to prevent
unauthorised access when idle, for computers used by system's support users.
2. Removes all unnecessary services from computers.
3. Uses file integrity monitoring software on servers (such as tripwire, etc.).
UTHSCSA Confidential Information Security Third-Party Assessment Survey Page 3 of 10

4. Changes or disables all vendor-supplied default passwords or similar “published”

access codes for all installed operating systems, database management systems,
network devices, application packages, and any other commercially produced IT
5. Uses passwords that are a min. of 8 characters, expire at least annually & have
complexity requirements.
6. Ensures that passwords are never stored in clear text or are easily decipherable.
7. Checks all systems and software to determine whether appropriate security
settings are enabled.
8. Manages file and directory permissions following least privilege and need-to-
know practices.
9. Implements redundancy or high availability for critical functions.
10. Authenticates all user access with either a password, token or biometrics.
11. Formally approves, tests and logs all system changes.
12. Uses artificial data in both development and test environments.
13. Limits access to development and test environments to personnel with a need to
14. Sets the account lockout feature for successive failed logon attempts on all
system's support computers.
15. Prohibits split tunneling when connecting to customer networks.
0 Total Configuration Controls
Answer Comments E. Product Design. The vendor: Comments
1. Ensures that if the product integrates with portable devices, confidential
information is encrypted when stored on these portable devices and requires
password access.
2. Ensures that access to confidential information, across a public connection, is
encrypted with a secured connection and requires user authentication.
3. Implements protections for CVEs in a timely manner to protect from exploits.
4. Audits the application against the OWASP Top 10 Application Security Risks.
5. Ensures that application server and database software technologies are kept up-
to-date with the latest security patches.
6. Uses threat modeling in their software development lifecycle (SDL).
7. Performs security code reviews as part of their SDL.
8. Conducts OWASP code reviews for the Top 9 source code flaw categories as part
of their SDL.
0 Total Product Design Controls
Answer Comments F. Compliance. The vendor: Comments
1. Will provide relevant certificates of applicable ISO 27001 certification.
2. Can provide documentation that its product is PITO compliant, if the vendor
manages any PHI on behalf of Company.
3. Can provide documentation of its PCI-DSS compliance if the vendor manages
any payment card information, on behalf of Company.
4. Uses industry standard best practices for application security (e.g. OWASP).
0 Total Product Design Controls
Answer Comments G. Access Control. The vendor: Comments
1. Immediately removes, or modifies access, when personnel terminate, transfer, or
change job functions.
2. Achieves individual accountability by assigning unique IDs and prohibiting
password sharing.
3. Ensures that critical data, or systems, are accessible by at least two trusted and
authorised individuals, in order to limit having a single point of service failure.
4. Ensures that users have the authority to only read or modify those programs, or
data, which are needed to perform their duties.
0 Total Access Controls
Answer Comments H. Monitoring. The vendor: Comments
1. Reviews access permissions monthly for all server files, databases, application,
UTHSCSA Confidential Information Security Third-Party Assessment Survey Page 4 of 10

2. Implements system event logging on all servers and records at a minimum who,
what, and when for all transactions.
3. Reviews and analyses after hours system accesses, at least monthly.
4. Reviews system logs for failed logins, or failed access attempts monthly.
5. Reviews and removes dormant accounts on systems at least monthly.
6. Reviews web server logs weekly for possible intrusion attempts and daily for
significant changes in log file size as an indicator of compromise.
7. Reviews network and firewall logs at least monthly.
8. Reviews wireless access logs at least monthly.
9. Performs scanning for rogue access points at least quarterly.
10. Actively manages IDS/IPS systems and alert notifications have been
11. Performs vulnerability scanning at least quarterly.This is a mandatory
requirement for all UBC EMRs.
12. Checks routinely that password complexity is adhered to.
0 Total Monitoring Controls
Answer Comments I. Physical Security. The vendor: Comments
1. Controls access to secure areas. E.g. key distribution management (both
physical and electronic), paper/electronic logs, monitoring of facility doors, etc.
2. Controls access to server rooms and follows least privilege and need-to-know
practices for those facilities.
3. Has special safeguards in place for computer rooms. e.g. cipher locks, restricted
access, room access log, card swipe access control, etc.
4. Shreds or incinerates printed confidential information.
5. Prohibits or encrypts confidential information on laptops & mobile devices.
6. Positions desktops, which display confidential information, in order to protect
from unauthorised viewing.
7. Escorts all visitors in computer rooms or server areas.
8. Implements appropriate environmental controls, where possible, to manage
equipment risks. E.g. fire safety, temperature, humidity, battery backup, etc.
9. Has no external signage indicating the content or value of the server room or any
room containing confidential customer information.
10. Provides an export copy of all of the customer's data in a mutually agreed upon
format at the end of the contract.
11. Follows forensically secure data destruction processes for confidential data on
hard drives, tapes & removable media when it's no longer needed and at the end of
the contract term.
0 Total Physical Controls
Answer Comments J. Contingency. The vendor: Comments

1. Has a written contingency plan for mission critical computing operations.

2. Has emergency procedures and responsibilities documented and stored securely
at multiple sites.
3. Reviews and updates the contingency plan at least annually.
4. Has identified computing services that must be provided within specified critical
timeframes, in case of a disaster.
5. Has identified cross-functional dependencies, so as to determine how the failure
in one system may negatively impact another one.
6. Has written backup procedures and processes.
7. Tests the integrity of backup media quarterly.
8. Stores backup media in a secure manner and controls access.
9. Maintains a documented and tested disaster recovery plan.
10. Uses off-site storage and has documented retrieval procedures for backups.
11. Password protects and encrypts all backups.
12. Provides rapid access to backup data.
13. Labels backup media appropriately, to avoid errors or data exposure.
0 Total Contingency Controls
Answer Comments K. Vendor's Business Associates. Comments
UTHSCSA Confidential Information Security Third-Party Assessment Survey Page 5 of 10

1. Confidentiality agreements have been signed before proprietary and/or

confidential information is disclosed to the vendor's business associates.
2. Vendor's business associate contracts, or agreements, are in place and contain
appropriate risk coverage for customer requirements.
3. Vendor's business associates are aware of customer security policies and what is
required of them.
4. Vendor's business associate agreements document the agreed transfer of
customer's data when the relationship terminates.
0 Total Business Relationships Controls


ACL: An access control list (ACL), with respect to a • Firewall ACLs
computer file system, is a list of permissions • File Permissions ACLs
attached to an object. An ACL specifies which users • Database ACLs
or system processes are granted access to objects,
as well as what operations are allowed on given
objects. Each entry in a typical ACL specifies a
subject and an operation. For instance, if a file has
an ACL that contains (Alice, delete), this would give
Alice permission to delete the file.

Business Critical Information - Indispensable

applications such as databases or process control
software that are deemed essential to the
functionality of a specific department.
Confidential Information - Protection of data where • Personally Identifiable Information [PII]:
it is required by law (e.g. Freedom of Information and •Student
Protection of Privacy Act [FIPPA] legislation, which •Prospective student
includes Personally Identifiable Information [PII] and •Personnel (faculty, staff, volunteers)
Protected Health Information [PHI]) or by industry •Donor or prospect
regulation (e.g. Payment Card Industry – Data • Protected Health Information [PHI]:
Security Standard [PCI-DSS] for protection of credit •Medical
card data) or by University of British Columbia policy. •Mental Health
•Personally identifiable patient data
• Financial
• Contracts
• Physical plant detail
• Credit card numbers (PAN data)
• Certain management information

CVE - Common Vulnerabilities and Exposures is a • Operating system vulnerabilities

reference-method for publicly-known information- • Application vulnerabilities
security vulnerabilities and exposures • Firmware vulnerabilities
Declassified To remove official security • A document is sufficiently stripped of all
classification from (a document). confidential material such that it is declassified to
public data
EMR - The Electronic Medical Record (EMR) • Health/Medical clinic electronic patient records
generally refers to an electronic version of the • Mental health counselling electronic records
traditional paper-based patient record used within a • Dental care electronic patient records
medical practice setting. The EMR is a • Physiotherapy electronic patient records
comprehensive record of health information
compiled during a direct patient-provider relationship
and is under the stewardship of the physician
providing primary care.

Institution Mission Critical Information -

Indispensable applications such as databases or
process control software that are deemed essential
to the functionality of Institution's education,
research, or patient care missions.
Intellectual Property - Property rights created Patent, trademark, copyright, trade secret, trade
through intellectual and/or discovery efforts of a dress, product, logo.
creator that are generally protectable by law.
Other Sensitive Information - Information other Internal departmental communications,
than the previous categories with little financial contractual information, negotiations, legal
impact; however, its unauthorised disclosure, concerns, investigations, etc.
alteration, loss, or destruction will at least cause
perceivable damage to someone or something.
PCI-DSS - Payment Card Industry-Data Security Credit Card, Charge Card, etc.
Standard describes how credit card data must be
protected. This standards was defined by the 5
major brands: VISA, MasterCard, American Express,
Discover & JCB.
PHI - Protected Health Information (sometimes • Data about a patient that can be used to • Address
referred to as Personal Health Information): uniquely identify an individual. • Account number
demographic information, medical history, test and • Billing records • Any vehicle or device serial number
laboratory results, insurance information and other • Hospital/medical records • Certificate/license number
data that is collected by a health care professional to • Lab, pathology and/or radiology results • Date of birth
identify an individual and determine appropriate • Mental Health records • E-mail address
care. • Physician/clinic records • Fax number
• Research data that contains health information • Finger or voice prints
that has identifiable individuals. • Health plan
• Research subject data involving health and/or • Internet Protocol (IP) address number
medicine. • Name
• PHI previously collected for research purposes • Name of employers
• Name of relatives
• Photographic images
• Postal address
• Social Insurance Number
• Telephone number
• Web universal resource locator (URL)

Physical Plant Detail: Physical plant or mechanical

plant (and where context is given, often just plant)
refers to the necessary infrastructure used in support
and maintenance of a given facility. The operation of
these facilities, or the department of an organisation
which does so, is called "plant operations" or facility
management. It should not be confused with
manufacturing plant.
Plant usually includes air conditioning (both • Any information about a student (or prospective
heating and cooling systems and ventilation) and student) that can uniquely identify a student. E.g.
other mechanical systems. It often also includes their e-mail address, phone number, name, SIN,
the maintenance of other systems, such as Date of Birth, etc.
plumbing and lighting. The facility itself may be • Non-business information about employees. E.g.
an office building, a school campus, military home phone, personal cell, home e-mail address,
base, apartment complex, or the like. SIN, home address, etc.
• Any information about donors or prospective
donors. E.g. name, e-mail address, phone
number, home address, etc.
• PHI - see above for definition and examples.
• Research subject data that may not be health or
medicine related.
What is Not PII:
• Employee name, employee work phone number,
employee work cell, employee work e-mail
address, employee work address, employee ID,

PITO (the Physician Information Technology

Office) - is an outcome of the 2006 Agreement,
Appendix C, where the provincial government and
the BC Medical Association agreed to work
collaboratively to "co-ordinate, facilitate and support
information technology planning and implementation
for physicians... including the development and
implementation in British Columbia of standardized
systems of electronic medical records (EMR)."
Security Code Review - is the process of auditing https://www.owasp.org/index.php/Code_Review_I
the source code for an application to verify that the ntroduction#What_is_Security_Code_Review.3F
proper security controls are present, that they work
as intended, and that they have been invoked in all
the right places. Code review is a way of ensuring
that the application has been developed so as to be
“self-defending” in its given environment.
Additional information can be found on the OWASP
web site:

SIN (Social Insurance Number) - A number issued 123-456-789

by the Canadian government to people for payroll
deductions for old age, survivors, and disability