Responsible Office: Office of Cybersecurity	Last Review: 03/01/2025 Next Review: 03/01/2027
Contact: Chris Madeksho	Phone: 901.448.1579 Email: mmadeksh@uthsc.edu

Purpose

To define practices and a formal process for Information Technology Services and the Office of Cybersecurity in the event of an information security violation.

Scope

All individuals are subject to the University of Tennessee Health Science Center (UTHSC) Information Security Program.

Definitions

Position of Authority – having official power to make important decisions. For cybersecurity, this is the Chief Information Security Office (CISO), the Chief Information Officer (CIO), or the persons they report to.

UTHSC Community – faculty, staff, residents, students, contractors, and other persons who conduct, in the performance of work at UTHSC, require access to University of Tennessee information.

Responsibilities

The Office of Cybersecurity is responsible for investigating reported violations and presenting the findings to the CISO and CIO.

The UTHSC Campus Community is responsible for reporting any security violations in a timely manner following IT0017-HSC-A-Security Incident Response.

Practice

1. Every member of the UTHSC Community must report Information security violations. Violations can be reported to the following:
   • UTHSC Office of Cybersecurity
   • UTHSC Office of the CIO
   • UTHSC ITS Service Desk
   • Police Department
   • Office of Institutional Compliance
   • UT Compliance Hotline
2. UTHSC will not retaliate against or permit reprisals against any faculty, staff, student, resident, contractor, or volunteer who reports a suspected violation of its policies protecting the confidentiality and integrity of UTHSC data or information. Allegations not made in good faith, however, may result in disciplinary action.
3. Substantiated violations of UT Policies and/or UTHSC Information Security Program protecting the confidentiality and integrity of UTHSC data or Information as determined by the Position of Authority may result in:
   • Disciplinary actions including dismissal
   • Mandatory corrective training
   • Immediate suspension of information systems access privileges
   • For employees: Notification of the individual’s supervisor
   • For students: Notification of the Vice Chancellor for Academic, Faculty, and Student Affairs
   • Invocation of disciplinary sanctions under the appropriate UT and/or UTHSC policies pertaining to faculty, staff, and students
   • Any action that may be required by applicable state or federal law, regulation or contract including, but not limited to, the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and the Family Education Rights and Privacy Act (FERPA)
   • Fees and/or fines. When appropriate and warranted, a department or unit may be held accountable for fees, charges, fines, or expenses incurred or resulting from or related to any such violation or non-compliance where the unit or department is deemed in whole or part responsible.
4. Disciplinary actions must be documented.
5. Disciplinary actions may be modified based on contributing factors. These factors, on a case-by-case basis, may include consideration of specific circumstances including, but not limited to:
   • Violation of specially protected information such as HIV-related, psychiatric, substance abuse, and genetic data
   • Volume of individuals or data affected
   • Level of exposure for the organization
   • Magnitude of organizational expense incurred, such as breach notifications
   • Hampering the investigation, lack of truthfulness
   • Negative influence on others
   • History of performance issues and/or violations
   • Work history

Policy History

Version #	Effective Date
1	03/17/2016
4	06/17/2020
5	05/13/2022
6	01/11/2023
7	03/01/2025 – new naming convention

References

1. IT0002-Acceptable Use of Information Technology Resources
2. IT0002-HSC-A-Acceptable Use of IT Resources
3. IT0003-HSC-A-UTHSC Information Security Program Strategy
4. IT0017-HSC-A-Security Incident Response