Endpoint Procedures

The procedures described in this section support the Registration and Protection of Endpoints Policy. Specific work instructions for implementing these procedures are the responsibility of the Certified IT Groups. Note that additional procedures for Medical Devices or other specialized equipment may be required.

Please see the main CUIMC Information Security Procedures page for an overview, effective date and definitions.

A. Managed Endpoints

All Endpoints purchased, or subsidized, by the University and used by Workforce members will be explicitly managed by a Certified IT Group. To be explicitly managed, the Endpoint (a “Managed Endpoint”) must meet the following criteria:

When a Workforce member changes functions or is no longer associated with the University, all Managed Endpoints used by the Workforce member must be returned to his/her supervisor. At this time, the endpoint inventory must be updated to reflect the current status of the endpoint, either decommissioning/disposal, reassignment with new owner noted, etc.

B. Personal Endpoints

The use of personally owned Endpoints (e.g. “Bring Your Own Device”, aka BYOD) to access secured CUIMC assets by a Workforce member is permissible only if the following conditions are met:

1. Request for Personal Endpoint Authorization

A department and associated CITG may, or may not, choose to allow members of their department to use personally owned endpoints. If they do, the following procedure applies:

  1. The User submits a Request for Personal Endpoint Usage form in the CUIMC IT ServiceNow system.
  2. The User’s supervisor is notified via email of the access request.
  3. The User’s supervisor reviews and approves or rejects the access request. If rejected, the User is notified via email for their approval.
  4. If approved, the User’s HIPAA Privacy and Security training status is evaluated and if all trainings are current, the approval is forwarded to the User’s Certified IT Group via email. If the trainings are not current, the User and the User’s supervisor are notified and the request is rejected.
  5. If approved, the User’s Certified IT Group configures the Endpoint so that it may be fully managed and enters it into the CUIMC Asset Management Database.
  6. The Endpoint is returned to the User for use. 

All requests will be documented, stored and maintained in the CUIMC IT ServiceNow system with an appropriate retention period.

When a Workforce member is no longer associated with the University, the workforce member’s department – via their Certified IT Group – is responsible for ensuring that any all CUIMC Data on his/her personally owned Endpoints is sanitized in accordance with the Sanitization or Disposal Procedures.

C. Data Backup

If any Endpoint is the primary repository of EPHI, the User of the Endpoint must comply with Section III(C) of the Business Continuity and Disaster Recovery Policy relating to Data Backup Plans.

D. Approved Usages of Removable Media

Workforce members may only use Removable Media that meet all of the following security criteria:

CUIMC IT maintains a list of approved Removable Media, and Certified IT Groups will only permit Removable Media that meet the above requirements to connect to Managed Endpoints.

At no time shall unencrypted Removable Media be used. Exceptions will be permitted on a case-by-case basis, if approved by a User’s supervisor as well as his/her certified IT Group. This exception can be requested through the Request for Encryption Exception form, as described in Managed Endpoints above.

When a Workforce member changes functions or is no longer affiliated with CUIMC, all Removable Media must be returned the User’s supervisor. Media may then be redeployed, in accordance with the Sanitization or Disposal of Internal Media and Removable Media procedure.

E. Third-Party Software Applications

All third-party software applications that do not process or store information directly on the endpoint must undergo an IT software review prior to use. This includes any applications, plug-ins, modules, or integrations, many of which may use external Cloud storage.

In accordance with the University’s policies for External Hosting and Registration And Protection Of Endpoints, users must contact their Certified IT Group well in advance to initiate an application review of a third-party software. Each department that owns or uses a third-party software is responsible for ensuring that the necessary review and approval is granted before deployment.

A review performed on third-party software may require different assessment workflows. Application assessments are evaluated based on criticality and sensitivity as determined by the software capabilities and interaction with institutional data as categorized under the University’s Data Classification policy.