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The CISO Decision Brief

Security Incident Management Policy

Commits the organisation to detecting, reporting, responding to and learning from incidents, and assigns authority to declare and escalate.

Available soon

Format
Word
Size
56 KB
Length
13 pages
Version
1.2
Updated

What's inside

What changed

  1. 1.2

    RD-10 now states DORA's rule for an incident classified as major only after 24 hours: the initial notification is due within 4 hours of that classification (Delegated Regulation (EU) 2025/301, Article 5(2)).

  2. 1.1

    IM-08 now says the incident manager contains at once with the least disruptive action, and brings in the service owner and specialists before stopping a service people depend on for safety or essential operations. The Policy-tier approver reads executive management, as the Policy Framework Standard sets it.

  3. 1.0

    Published.

Changes across this pack

Preview

The document from section 1, as you will receive it. Highlighted [[text]] is for you to replace; shaded guidance boxes are for you to delete before approval. The cover and document control pages are in the file.

Purpose

This policy commits [[Organisation Name]] to detecting, reporting, responding to and learning from information security incidents, so that harm is stopped quickly, the people and authorities who must be told are told on time, and the same incident does not happen twice. It gives named roles the authority to declare an incident, to escalate it, and to take the decisions that cannot wait, and it says who may take the decisions that can.

It is short on purpose. The Incident Response Plan says how the response runs, the Incident Classification, Severity & Escalation Matrix sets the severity levels and the reporting clocks, and the playbooks and templates in the Security Incident Management pack carry out the steps. The rules below are the part that does not change from one incident to the next.

Scope

This policy applies to:

  • Events and incidents: every suspected or actual event that could affect the confidentiality, integrity or availability of [[Organisation Name]]'s information, systems or services, in any form — electronic, on paper or spoken — including personal data breaches, lost or stolen devices and incidents at suppliers that affect our data or services.
  • Locations and systems: all sites, offices and remote working locations, and all systems and services we own, rent or use, including cloud services and systems run for us by suppliers.
  • People: everyone who works for or with [[Organisation Name]] — employees, contractors, temporary staff and suppliers' staff with access to our systems or data — and the roles named in this policy.

Excluded: [[anything deliberately left out, and where it is covered instead, e.g. physical safety incidents covered by the health and safety policy — or "None"]]. An incident that starts as something else — a fraud, an outage, a complaint — comes under this policy as soon as information security is involved.

Guidance — delete before approval

Keep the scope wide. Most incidents are reported first as something else: a strange email, a slow system, a customer complaint, a lost phone. If the scope is "IT security incidents" only, the ones that matter most in law — a spreadsheet of personal data sent to the wrong person, a supplier's breach — may never reach the incident manager.

An incident at a supplier is in scope when it affects our data or services (category IC-10); the Third-Party Security Policy (Third-Party Security Risk Management pack) makes sure critical suppliers are part of the response.

Policy statements

The Incident Classification, Severity & Escalation Matrix sets the severity levels, the categories and the reporting clocks the statements refer to; the Incident Response Plan sets the roles, the phases and the decision rights; the Incident Triage & First-Hour Assessment Procedure sets the steps of triage and the first hour.

Reporting and triage

IM-01 Everyone must report a suspected security event at once through the reporting route; nobody is blamed for a report made in good faith.

Evidence: the reporting route [[phone number, email address and portal]], published at [[location everyone in scope can reach]] and in induction material; every report in the Incident Case & Action Log with the time and the reporter; no disciplinary record that arises from a report made in good faith.

IM-02 Triage of every reported event must start within 30 minutes of the report in working hours and 60 minutes outside them, and must end within [[30]] minutes of starting with the event closed with a recorded reason or declared an incident.

Evidence: the time each report was received, the time triage started and the time it ended in a decision, in the Incident Case & Action Log; for every event closed without declaration, the reason.

Classification and escalation

IM-03 Every declared incident must have one named incident manager, a case number, a category and a severity, recorded at declaration.

Evidence: for every incident in the Incident Case & Action Log: the case number, the incident manager, the category and the severity, each recorded at the time of declaration.

IM-04 Severity must be set on the worst impact the incident has had or is capable of having, choosing the higher level when in doubt; it must be reviewed at every update and lowered only with a recorded reason.

Evidence: the severity recorded at each update; for every lowering, who lowered it and why.

IM-05 Severity 1 and 2 incidents must be escalated to the executive incident lead, and Severity 1 incidents to the board chair or equivalent, within the times the matrix sets.

Evidence: the time each person was told, in the Incident Case & Action Log, against the times the Incident Classification, Severity & Escalation Matrix sets for the severity.

Reporting duties

IM-06 Every incident must be screened against every reporting duty (NIS2, GDPR, DORA where it applies, contracts and insurance) within 4 hours of declaration, and the decision and its reasons recorded whether or not a report is made.

Evidence: a completed reporting screen for every incident, made within 4 hours of declaration, recording each decision and its reasons — including every decision not to report; the breach record for every personal data breach, notified or not.

Response and evidence

IM-07 Evidence must be preserved before systems are wiped or rebuilt, unless waiting would let the harm spread; who handled it, and when, must be recorded.

Evidence: the evidence log for each incident: what was collected, by whom, when, and where it is held; for any system wiped or rebuilt before evidence was collected, the reason.

IM-08 The incident manager must act at once to stop harm spreading, with the least disruptive containment that does it, and must bring in the service owner and specialists before any action that would stop a service people depend on for safety or essential operations; waiting for an executive is never a reason to let harm spread. A decision to stop a customer-facing service must be taken by the executive incident lead, or by the incident manager where waiting would let the harm spread; a ransom may only be paid on the decision of the board or its equivalent.

Evidence: the decision log: each containment action, who took it, when and why; for any action that stopped a service people depend on for safety or essential operations, the service owner and specialists brought in before it; who stopped a customer-facing service, when and why; for any ransom or extortion demand, the minutes of the board's decision.

Communications

IM-09 Only the communications lead may speak for the organisation about an incident outside it, using the approved templates; nobody else may talk to the media or post about an incident.

Evidence: every message sent outside the organisation about an incident, made from a template in the Incident Communications Template Set, with its approver and the time it was sent.

Recovery and learning

IM-10 A system must not return to normal service until the recovery criteria are met, and backups must be checked for integrity before they are restored.

Evidence: a recovery sign-off for every system returned to service, showing each recovery criterion met, including the backup integrity check, and the name of the system owner who confirmed it.

IM-11 Every Severity 1 and 2 incident must have a post-incident review within 10 working days of closure; its actions must have owners and due dates, and the risks it touches must be reassessed (P05 RM-10).

Evidence: the review report for every Severity 1 and 2 incident, made with the Post-Incident Review Template within 10 working days of closure; each action with an owner and a due date in the Incident Case & Action Log; the reassessment of the risks it touched in the Information Security Risk Register.

Testing and reporting

IM-12 The plan must be exercised at least once a year and reviewed after every Severity 1 incident; incidents by severity, reports made on time and overdue review actions must be reported to executive management every quarter.

Evidence: the report of each exercise; the revision history of the Incident Response Plan showing a review after each Severity 1 incident; the quarterly report to executive management with IMM-01, IMM-02, IMM-03, IMM-04.

Guidance — delete before approval

The statements keep the rule IDs IM-01 to IM-12 that every document in the Security Incident Management pack cites. Do not renumber them. If you remove one, keep its number and mark it "Withdrawn in version x.y", so records that cite it still point to the right text.

The severity levels are Severity 1 (Critical), Severity 2 (High), Severity 3 (Medium), Severity 4 (Low). The times in IM-02 and the 4-hour screen in IM-06 are the pack's defaults; if you change them, change them in the Incident Classification, Severity & Escalation Matrix and the Incident Triage & First-Hour Assessment Procedure too. Never set a time that leaves too little of a legal clock: the NIS2 early warning is due within 24 hours of awareness.

Roles and responsibilities

Each role has a named deputy, recorded in the contact directory of the Incident Response Plan. A deputy has the same authority as the role while acting in it.

Role

Responsibilities under this policy

Executive management

[[e.g. Executive Committee]]

Approves this policy; receives the quarterly report (IM-12); makes sure the response has the people, suppliers and budget it needs.

Board

[[the board chair, or the equivalent where there is no board]]

Is told of every Severity 1 incident within the time the matrix sets (IM-05); alone decides whether a ransom or extortion demand is paid (IM-08).

Executive incident lead

[[e.g. Chief Operating Officer, with a named deputy]]

Is told of every Severity 1 and 2 incident (IM-05); decides on stopping customer-facing services (IM-08) and on reports to authorities; approves what is said outside the organisation (IM-09); leads the crisis team.

Incident manager

[[e.g. Information Security Manager, with a named deputy]]

Declares incidents and sets category and severity (IM-03, IM-04); runs the response; escalates (IM-05); completes the reporting screen (IM-06); contains at once with the least disruptive action that stops the harm: may isolate systems, sites and accounts, and stop a service where waiting would let the harm spread, bringing in the service owner and specialists first where people depend on it for safety or essential operations (IM-08); keeps the case log.

Head of Information Security

[[e.g. Head of Information Security or CISO]]

Owns this policy and the Incident Response Plan; runs the post-incident reviews (IM-11) and the yearly exercise (IM-12); prepares the quarterly report.

IT service desk

[[internal service desk, or the managed IT provider's]]

Receives reports and triages them within the times in IM-02; handles Severity 4 incidents; passes anything larger to the incident manager at once.

Technical responders

[[IT operations, the managed IT provider and the security monitoring provider]]

Contain, investigate, eradicate and recover under the incident manager's direction; preserve evidence (IM-07); check backups before restoring (IM-10).

Data Protection Officer

[[or the privacy lead where no DPO is appointed]]

Advises on every incident that involves personal data; assesses the risk to individuals; keeps the breach record (IM-06).

Legal

[[in-house or external counsel]]

Advises on reporting duties, contracts, evidence and law enforcement; advises the board before any decision on a ransom (IM-08).

Communications lead

[[e.g. Head of Marketing and Communications]]

Is the only voice of the organisation outside it about an incident, using the approved templates (IM-09).

Reporter

anyone: staff, contractors, suppliers or customers

Reports anything suspicious at once through the reporting route (IM-01); does not investigate, delete or forward suspicious material unless told to.

Guidance — delete before approval

Replace each [[example]] with the role that holds it in your organisation, and name a deputy for every role in the Incident Response Plan. The incident manager and the executive incident lead must be different people: one runs the response, the other takes the decisions with business impact and answers for them.

Compliance and consequences

How compliance is checked. The Head of Information Security checks compliance with this policy every quarter by sampling the Incident Case & Action Log: triage times against IM-02, escalation times against the matrix (IM-05), a reporting screen for every incident (IM-06), and review actions against their due dates (IM-11). [[Internal audit]] tests a sample of [[5]] incident records [[every year]], including at least one event that was closed without declaration. The results are reported to executive management every quarter (IM-12) with these measures:

Measure

What it counts

Target

IMM-01 Significant incidents and time to contain

Incidents reported to an authority as significant (NIS2) or major (DORA) in the quarter, and for each the hours from detection to containment.

Each contained within [[24]] hours

IMM-02 Reports made on time

Reports to authorities and individuals made by their deadline, out of all that fell due in the quarter.

All

IMM-03 Review actions overdue

Open post-incident review actions past their due date.

None more than 30 days overdue

IMM-04 Months since the plan was last exercised

Whole months from the last exercise of the plan (not a live incident) to the end of the quarter.

12 or fewer

IMM-01 is the board measure BM-04 in the Board Metric Selection Catalogue (Board Cybersecurity Reporting pack): the board sees the same number the executive does.

Consequences of not complying. Nobody is disciplined for reporting in good faith, for a false alarm, or for a mistake they report themselves (IM-01). Hiding or delaying the report of an incident, destroying evidence, or speaking about an incident outside the organisation without authority (IM-09) may lead to action under the [[disciplinary procedure]]. A report to an authority made late because this policy was not followed is itself reported to executive management, with its cause. For a supplier, not meeting the incident duties of its contract is a breach of that contract, handled under its terms.

Guidance — delete before approval

EXAMPLE, from the example organisation used across the pack (a wholesale distributor with about 900 staff, three warehouses and an online ordering service that takes 60% of its orders), for Q3 2026:

IMM-01 Significant incidents and time to contain: 1 significant incident; contained in 6 hours.

IMM-02 Reports made on time: 4 of 4.

IMM-03 Review actions overdue: 1 (PIA-04, 5 days).

IMM-04 Months since the plan was last exercised: 6 months (last exercise 18 Mar 2026).

Replace these with your own figures, as at the date of your report.

Exceptions

Any deviation from this policy must be requested, assessed and approved under the Security Exception & Waiver Standard [[document ID]], using the Security Exception Request & Approval Form, before the deviation begins. An exception is time-limited and recorded in the Security Exception Register. Agreement by email, in a meeting or by a manager is not an exception.

An exception can change how this organisation meets a rule — for example a longer triage time out of hours at a site with no monitoring — but never a legal duty. A report to an authority, to individuals or to a controller is due when the law says, exception or not (IM-06). During an incident, the incident manager and the executive incident lead act within their decision rights; an action taken outside them is recorded in the case log and reviewed afterwards, not approved as an exception.

Guidance — delete before approval

Keep the first paragraph as it is; change only the document reference. The most common exceptions under this policy are out-of-hours triage times and the yearly exercise. Record them, with an expiry date, rather than letting them lapse quietly.

Document

Relationship

Incident Response Plan

The response organisation, phases, decision rights, deputies and contact directory (IM-03 to IM-12)

Incident Classification, Severity & Escalation Matrix

The severity levels, categories, escalation times and reporting clocks (IM-03 to IM-06)

Incident Triage & First-Hour Assessment Procedure

The steps of triage and the first hour after declaration (IM-02, IM-03, IM-06)

Ransomware Response Playbook; Business Email Compromise Response Playbook; Personal Data Breach Response Playbook

The response to the categories that need their own steps (IM-07, IM-08, IM-10)

Incident Case & Action Log

Every event, incident, decision, report and review action (IM-01 to IM-11)

Incident Communications Template Set

The approved messages, inside and outside the organisation (IM-09)

Post-Incident Review Template

The post-incident review and its actions (IM-11)

Incident Response Readiness Checklist

Whether the plan, the people and the tools are ready (IM-12)

Risk Assessment Methodology & Scoring Model; Information Security Risk Register

The impact scale severity is judged on, and where the risks an incident touches are reassessed (IM-04, IM-11); Information Security Risk Management pack

Third-Party Security Policy

Critical suppliers' part in incident response, with named contacts and notification duties; Third-Party Security Risk Management pack

Security Exception & Waiver Standard

The route for every exception to this policy; Security Exception, Waiver & Segregation of Duties pack

Board Metric Selection Catalogue

The board measure BM-04, which IMM-01 reports; Board Cybersecurity Reporting pack

[[Information Security Policy]]

[[Parent policy]]

[[Business continuity plan]]

[[How services are kept running and restored when an incident disrupts them]]

Definitions

Term

Meaning in this policy

Event

Something observed or reported that might affect the security of our information or services. Most events are not incidents.

Near miss

An event that could have compromised our data or services but was prevented or did not happen, and needs nothing beyond logging. Logged, never declared. An attack that was stopped but still needs response work, such as warning a supplier, confirming a patch or watching for a repeat, is declared, usually at Severity 4.

Incident

An event, declared by the incident manager, that has compromised, or threatens to compromise, the availability, authenticity, integrity or confidentiality of our data or services, and needs a managed response.

Significant incident

NIS2's term: an incident that has caused or could cause severe operational disruption or financial loss to us, or considerable damage to others. Reported to the authority on NIS2's clock.

Major ICT-related incident

DORA's term, for financial entities only: an ICT-related incident with a high adverse impact on systems that support critical or important functions, as tested by Delegated Regulation (EU) 2024/1772.

Personal data breach

GDPR's term: a breach of security leading to the accidental or unlawful destruction, loss, alteration, unauthorised disclosure of, or access to, personal data.

Severity

One of four levels — Severity 1 (Critical), Severity 2 (High), Severity 3 (Medium), Severity 4 (Low) — set by the Incident Classification, Severity & Escalation Matrix. Severity says how fast we respond; it is not the same as any of the three legal tests above, which are checked separately (IM-06).

Category

One of the 10 kinds of incident, IC-01 to IC-10, in the Incident Classification, Severity & Escalation Matrix. The category chooses the playbook.

Declaration

The incident manager's decision, recorded in the case log, that an event is an incident.

Awareness

The moment the reporting clocks start: the time the incident is declared, as recorded in the case log, unless the record shows we had reasonable certainty earlier, in which case the earlier time.

Reporting screen

The check of every reporting duty (NIS2, GDPR, DORA, Contract, Insurance, Law enforcement) made within 4 hours of declaration (IM-06).

Containment

The incident can no longer spread or cause new harm, even though systems may not yet be restored.

Closure

Recovery criteria met, the monitoring period passed without recurrence, and the case log complete.

Case log

The Incident Case & Action Log: the record of every event, incident, decision, report and action.

Document control

Approval record

Version

Approved by

Date

Evidence of approval

Next review by

[[1.0]]

[[Executive management]]

[[YYYY-MM-DD]]

[[e.g. minutes of meeting, reference and item]]

[[YYYY-MM-DD]]

Review. This policy is reviewed at least every 12 months, and sooner after: a major incident, or an incident the document should have prevented; a material change to the organisation's activities, systems or suppliers; a change in law, regulation or a contract the document supports; an audit or assessment finding against the document; a significant change in the threats the document addresses. A Severity 1 incident always triggers a review of the Incident Response Plan (IM-12), and of this policy if the review found a rule missing or wrong. The revision history is at the front of this document.

Publication. The current approved version is published at [[location everyone in scope can reach]]. The reporting route (IM-01) is also published on its own, where people will see it when something goes wrong: [[e.g. the intranet home page, the back of building passes, the IT service desk portal]].

Guidance — delete before approval

This is a Policy-tier document: approved by executive management. Nobody approves a document they own or wrote: if the owner sits on the approving body, the rest of it approves.

Adapting this template

Guidance — delete before approval

Small organisation: keep all twelve statements; they cost little when incidents are few. One person may be both incident manager and Head of Information Security, but the executive incident lead must be someone else, usually the managing director. Where nobody is on call out of hours, give the out-of-hours triage to your IT provider or security monitoring provider under contract, and make the reporting route reach them. The yearly exercise (IM-12) can be a two-hour discussion around one scenario.

Regulated entity: an essential or important entity under NIS2 must have incident handling among its risk-management measures (Article 21(2)(b)) and must report significant incidents on the clocks RD-01 to RD-05 set, starting with an early warning within 24 hours of awareness; IM-06 makes the screen early enough to meet them. A financial entity under DORA reports major ICT-related incidents under DORA instead of NIS2 (NIS2 Article 4(1), DORA Article 1(2)): replace RD-01 to RD-05 with RD-10 initial notification (within 4 hours of classifying the incident as major, and no later than 24 hours after awareness; where it is classified as major only after those 24 hours, within 4 hours of that classification); RD-11 intermediate report (within 72 hours of the initial notification, and again when regular activities are recovered); RD-12 final report (no later than one month after the latest intermediate report); RD-13 notice to clients (without undue delay). DORA also requires an ICT-related incident management process (Article 17(1)) and classification by its own criteria (Article 18(1)); name this policy and the Incident Classification, Severity & Escalation Matrix as that process and classification. Under the GDPR, every controller notifies the supervisory authority without undue delay and, where feasible, within 72 hours of awareness; later only with reasons for the delay unless the breach is unlikely to result in a risk to individuals, and documents every breach, notified or not (Article 33(5)).

IT run by a service provider: your managed IT provider is often the service desk and most of the technical responders. Its contract must oblige it to pass on reports at once, triage within the times in IM-02, preserve evidence (IM-07) and follow the incident manager's direction; the Third-Party Security Policy and its clauses on incident notification and cooperation cover this. Declaration, severity, the reporting screen and every decision in IM-08 stay with your own people: a provider can advise, but it cannot decide for you or report for you. If you are yourself a managed service or managed security service provider, NIS2's Implementing Regulation (EU) 2024/2690 sets the cases in which your incidents are significant; build them into the Incident Classification, Severity & Escalation Matrix.

Delete this section before approval.

Framework references

These references show where this document supports an external framework. They indicate relevance only and do not reproduce the text of any standard. Editions referenced: ISO/IEC 27001:2022 incl. Amd 1:2024; NIST CSF 2.0; Directive (EU) 2022/2555 (NIS2) and Implementing Regulation (EU) 2024/2690; Regulation (EU) 2016/679 (GDPR); Regulation (EU) 2022/2554 (DORA), Delegated Regulations (EU) 2024/1772 and 2025/301, Implementing Regulation (EU) 2025/302.

Framework

Reference

Supported by

ISO/IEC 27001:2022

Clause 5.2 — Policy

Whole policy: approved by executive management, communicated, reviewed

ISO/IEC 27001:2022

Annex A 5.24 — Information security incident management planning and preparation

Whole policy; roles and responsibilities; IM-03, IM-12

ISO/IEC 27001:2022

Annex A 5.25 — Assessment and decision on information security events

Triage and declaration (IM-02 to IM-04)

ISO/IEC 27001:2022

Annex A 5.26 — Response to information security incidents

Response, escalation and decisions (IM-05, IM-08, IM-10)

ISO/IEC 27001:2022

Annex A 5.27 — Learning from information security incidents

Post-incident review and actions (IM-11)

ISO/IEC 27001:2022

Annex A 5.28 — Collection of evidence

Evidence preserved and its handling recorded (IM-07)

ISO/IEC 27001:2022

Annex A 6.8 — Information security event reporting

Everyone reports at once through the reporting route (IM-01)

NIST CSF 2.0

GV.PO-01 — “Policy for managing cybersecurity risks is established based on organizational context, cybersecurity strategy, and priorities and is communicated and enforced”

Whole policy: approved, communicated and checked for compliance

NIST CSF 2.0

GV.RR-02 — “Roles, responsibilities, and authorities related to cybersecurity risk management are established, communicated, understood, and enforced”

Roles and responsibilities; decision rights (IM-08, IM-09)

NIST CSF 2.0

DE.AE-08 — “Incidents are declared when adverse events meet the defined incident criteria”

Declaration (IM-02, IM-03)

NIST CSF 2.0

RS.MA-04 — “Incidents are escalated or elevated as needed”

Escalation (IM-05)

NIS2 — Directive (EU) 2022/2555

Article 21(2)(b) — the cybersecurity risk-management measures include “incident handling”

Whole policy; regulated-entity tailoring

NIS2 — Directive (EU) 2022/2555

Article 23(1) — notify the CSIRT or competent authority, without undue delay, of any significant incident; where appropriate, notify the recipients of the services of significant incidents likely to adversely affect those services

The reporting screen (IM-06); regulated-entity tailoring

GDPR — Regulation (EU) 2016/679

Article 33(1) — notify the supervisory authority “without undue delay and, where feasible, not later than 72 hours after having become aware of it”, unless the breach is unlikely to result in a risk to the rights and freedoms of natural persons; a later notification gives reasons for the delay

The reporting screen (IM-06)

GDPR — Regulation (EU) 2016/679

Article 33(5) — the controller documents every personal data breach: the facts, its effects and the remedial action taken

The breach record for every personal data breach (IM-06)

NIS2 — Implementing Regulation (EU) 2024/2690

Article 3 — the cases in which an incident is significant for the digital providers named in Article 1 (among them cloud computing, data centre, managed service and managed security service providers)

Service-provider tailoring: when a managed service provider's incident is significant

NIS2 — Directive (EU) 2022/2555

Article 4(1) — where a sector-specific Union legal act requires entities to notify significant incidents with requirements at least equivalent in effect, the relevant provisions of NIS2 do not apply to those entities

Regulated-entity tailoring: DORA's reporting replaces NIS2's for financial entities

DORA — Regulation (EU) 2022/2554

Article 1(2) — for financial entities identified as essential or important entities under NIS2, DORA “shall be considered a sector-specific Union legal act for the purposes of Article 4” of NIS2

Regulated-entity tailoring: DORA is the sector-specific act for NIS2 Article 4

DORA — Regulation (EU) 2022/2554

Article 17(1) — define, establish and implement an ICT-related incident management process to detect, manage and notify ICT-related incidents

Whole policy as part of the ICT-related incident management process; regulated-entity tailoring

DORA — Regulation (EU) 2022/2554

Article 18(1) — classify ICT-related incidents by clients and transactions affected, reputational impact, duration and downtime, geographical spread, data losses, criticality of services affected and economic impact

Regulated-entity tailoring: classification by DORA's criteria

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