University IT

Purpose

Introduction

General Principles

• Academic Freedom: Academic freedom is a fundamental University value. This Policy will be administered in a manner that supports the principle of academic freedom.
• Supportive Academic Environment: The University of Rochester seeks to provide a supportive working, living, learning and clinical environment. To accomplish this, we actively look for ways to encourage exchange and discourse, to bring together faculty, students, and staff, and to build a community that encourages all of its members to succeed and grow.
• Accountability for University Resources: All members of the University community have responsibility to protect University resources for which they have access or custodianship. Members of the University community are accountable for their access to and use of University resources.
• Personal Use and Privacy: The University recognizes that students, faculty and staff have reasonable expectations of privacy in their uses of Information Technology Resources. However, rights to privacy are constrained in the University environment because (1) the University owns and supplies these Information Technology Resources to its faculty, staff and students fundamentally for the purpose of accomplishing its academic and patient care missions, (2) the Information Technology Resources contains many closely shared environments and resources and the rights of other users must be taken into account and (3) legal and ethical restrictions apply. Individuals may have access to unconstrained use through private or commercial systems located at their residence or elsewhere. Resources or systems owned and maintained by the University for the benefit of the academic community are primarily intended for use for the University, not personal or business communications.
• Relationship to Division or Departmental IT Policies: Divisions and Departments within the University may adopt additional information technology policies that are specific to their operations, provided that such requirements are consistent with this Policy and the unit provides a copy of more specific unit policies to the University Chief Information Officer. In the event of inconsistency, the provisions of this Policy will prevail, unless the more specific policies are necessary to meet legal requirements governing certain types of information, in which case the more specific legal requirements and related policy will take precedence. 

Scope

• People to Whom Policy Applies: This Policy applies to everyone who accesses University Information Technology Resources, whether affiliated with the University or not, whether on campus or from remote locations, including but not limited to students, faculty, staff, contractors, UR Information Technology Policy Page 3 of 10 consultants, temporary employees, guests, and volunteers. By accessing University Information Technology Resources, the user agrees to comply with this Policy.
• Definition of Information Technology Resources: Information Technology Resources for purposes of this Policy include, but are not limited to, University-owned transmission lines, networks, wireless networks, servers, exchanges, internet connections, terminals, applications, and personal computers. Information Technology Resources include those owned by the University and those used by the University under license or contract, including but not limited to information recorded on all types of electronic media, computer hardware and software, paper, computer networks, and telephone systems. Information Technology Resources also includes, but is not limited to, personal computers, servers, wireless networks and other devices not owned by the University but intentionally connected to the University-owned Information Technology Resources (other than temporary legitimate access via the world wide web access) while so connected. 

Privacy

Access Restrictions for Personal Communications

The University will not, without user permission, monitor, review or otherwise access Personal Communications (defined below) sent or received (e.g., email), created or stored on Information Technology Resources, except pursuant to the Access Procedures set forth in Section II, which permits access when determined reasonable by a senior administrative officer or for Information Technology Management. The reasons for which access to Personal Communications can be granted include, but not are limited to, the following circumstances: 

• To investigate or prevent a violation of law or University Policy; 
• To protect health or safety or to provide assurance to the University or to health or other regulators or law enforcement authorities that harm has not occurred to patients, students or others; 
• To minimize or stop computer activity that interferes with the University’s network or other computer operations; 
• To comply with a subpoena, warrant, court order or similar legal process, including a discovery request or a litigation stay order issued by or investigation undertaken by the Office of Counsel in connection with a potential claim in anticipation of litigation; OR 
• When the user is unwilling, unable or unavailable to consent, to access Personal Communications needed by another University employee in order to fulfill a teaching, research, patient care or other legitimate University function. 

The access restrictions and approval process of this Policy do not apply to electronic communications and records supporting University Communications when accessed by authorized individuals for the purpose of carrying out University Business. The approval process described below applies only if access is sought to Personal Communications. 

“Personal Communications” are limited to faculty and student research, teaching, learning or personal (i.e. non-University related) emails, documents and correspondence. All other emails, documents, and correspondence prepared by a faculty member, student or employee in connection with his or her job responsibilities are defined as “University Communications” and may be accessed as needed for the purpose of carrying out University Business without seeking prior approval. 

“University Business” refers to the University’s activities and functions, including, but not limited to, administrative functions in the areas of teaching, student life, patient care and research, as well as supportive administrative services. It includes all information related to patient care, although this information is subject to HIPAA and other patient privacy restraints. 

Access Procedures

University Communications

University Communications may be accessed for the purpose of carrying out University Business by individuals with authority to deal with communications related to their subject matter without prior permission from a University official. The purpose of the access is critical to the determination that prior permission from a University official is not necessary for access. 

It is understood in the environment of Information Technology Resources that there may not always be a physical separation of electronic records between University Business and Personal Communications. If material is found during a legitimate search for University Communications that indicates a potential violation in Personal Communications of University policy, including this Policy, or illegal use, the individual(s) involved in the search should halt the search, secure the relevant Information Technology Resources and seek permission to access the Personal Communications under the procedure set forth under section B. Users are reminded of the General Principle in Section I that resources and systems owned and maintained by the University are intended for use for the University and not for personal or business communications. Individuals who want unconstrained use and privacy should use private or commercial systems located at their residence or elsewhere, not University IT Resources. Individuals using University IT Resources should recognize that complete privacy is not assured and should refrain from creating or keeping on University IT Resources communications that they wish to keep private. 

Personal Communications

With respect to personal communications, anyone seeking access to Electronic Files(1) of an Employee or Student without user consent must first present to a senior University official (President, Provost, Vice President of the University or Medical Center, Dean, CEO of Strong Memorial Hospital, Director of LLE or Director of MAG, and Vice Provost and Chief Information Officer, the “Official”) reasonable cause for gaining such access. (See section I for examples of reasonable cause.) If the initiator of the request is a senior University Official, the request must be approved by another senior University Official. If the initiator of the request is the University President, the request must be approved by the Vice President and General Counsel. An individual cannot initiate a request for access and also be part of the decision-making process. Permission should generally be sought from the official in charge of the school or division relevant to the search if that official is available. 

______________________________

(1)“Electronic Files” is defined as data files stored on University servers
by any University employee including members of the Faculty or by any 
University student. Examples include communications, memos, meeting minutes, 
telephone logs, diaries or calendars, and any other files stored on
University servers.

______________________________

In requesting access to Personal Communications without user consent, the person seeking access should provide to the Official relevant information available to support the reasonable cause. The request regarding access should be in writing (email is preferable) to the Official with a copy sent to the Vice President and General Counsel. The decision of the Official must be in writing (email is preferable) directed to the person requesting access with a copy to the Vice President and General Counsel and, if access is granted, a copy to the Information Technology team member who will oversee access. 

A. Preservation and Internal Review of Electronic Files by the Office of Counsel 

1. University IT or URMC ISD will create and maintain for ten years from completion of the related investigation a record of all requests to preserve, duplicate and/or provide to the Office of Counsel the contents of electronic files created or maintained by any Employee or Student of the University. The information captured on the log will include the identity of the individual approving the request and specify the action taken by University IT or URMC ISD in response to the request. 
2. All requests to University IT or URMC ISD to preserve, duplicate or provide Electronic Files will be responded to in strict compliance with this Policy. 
3. When Electronic Files are provided for review to the Office of Counsel, notice (with sufficient specificity to describe the files subject to review) to the Employee or Student who created or maintains the electronic file(s) at issue will be provided by the Office of Counsel as soon as practicable unless notice should be delayed at the direction of law enforcement, the Department of Public Safety, or the Office of Counsel. Any decision of the Office of Counsel to delay disclosure must be based on preservation of confidentiality of an active investigation and any delay in notifying such Employee or Student that extends beyond three weeks will require the approval of the President. 
4. Electronic files that are preserved, duplicated or provided to the Office of Counsel will be retained on a secure server or dedicated digital media maintained by University IT or URMC ISD and will have the same level of security as other University email systems. 
5. University IT or URMC ISD will create and preserve an exact copy of the electronic files provided to the Office of Counsel for a period of ten years. 

B. Distribution of Electronic Files beyond the Office of Counsel 

1. If the Office of Counsel determines that access to electronic files must extend beyond the Office of Counsel, consent of the University President shall be obtained before access is granted. Upon Presidential consent, University IT or URMC ISD will create an exact copy of any electronic files that will be shared or provided. The exact copy of the files and the documentation of the approval process will be retained on a secure server or dedicated digital media maintained by University IT/ISD for ten years, and will have the same level of security as other University email systems.
2. Upon Presidential consent, the Office of Counsel will notify the individual(s) who created or maintained the electronic files. Such notice will be provided as soon as practicable unless, at the direction of law enforcement, the Department of Public Safety or the Office of Counsel, notice should be delayed. Any decision of the Office of Counsel to delay disclosure must be based on preservation of confidentiality of an active investigation and any delay in notifying such Employee that extends beyond three weeks will require the approval of the President. 
3. This section does not apply to electronic files shared with outside counsel or litigants, administrative or governmental agencies, or courts of law. Nothing in this section is meant to restrict the University’s legal and the Office of Counsel’s ethical obligations to comply with governmental investigations, laws or rules governing discovery or disclosure in legal or administrative actions, or to comply with any court order or subpoena for records. 

C. Oversight of Review and Distribution of Electronic Files 

Oversight of this activity will be the responsibility of the University IT Policy Committee and shall include faculty representatives. University IT will produce an annual report to the University IT Policy Committee, showing aggregated and de-identified requests received since the last report to preserve, duplicate and/or provide the contents of electronic files created or maintained by employees. 

The Office of Counsel will produce an annual aggregated and de-identified report of any disclosures made as described in Paragraph B (1), and those disclosures will be retrospectively reviewed by the IT Policy Committee. In the event of a disclosure of Electronic Files as described in Paragraph B (1) created or maintained by a Student, the IT Policy Committee will include a student as an ad hoc member for the limited purpose of reviewing that disclosure. Faculty senate executive leadership may request reports and clarification from the Secretary of the University IT policy committee, and such reports will maintain respect for the privacy concerns of the individual. 

Some University employees, to perform their assigned duties, must have special privileges to access hardware and software, including specific files. Such employees are expected to abide strictly by this Policy, and are subject to discipline, including termination, for violating it. 

In emergency situations in order to prevent destruction of equipment or data, it may be necessary for the University to seize or otherwise secure computers or other information technology pending initiation under this Policy concerning access to the information contained therein. The University reserves this right with respect to information technology governed by this Policy. 

Information Technology Management and Audit

The University may use mechanisms to manage the information technology operations, including (but not limited to) spam and virus detection and elimination; limitation of network volume or blockage of access to specify file types or sites; or restriction of access to sites that present a security risk to the University’s systems or experience high volumes of network traffic unrelated to the academic missions of the University. Use of such mechanisms must be approved by Director level University Information Technology (University IT) staff or any other person designated by the Chief Information Officer and must be consistent with legitimate University business needs. It may be necessary for the Office of University Audit or the University’s outside auditors in the course of an audit to access Information Technology Resources and information stored thereon. Audits are authorized by the Board of Trustees or by a senior University officer and are governed by protocols that protect unnecessary disclosure of information. 

Data Classifications and Access Restrictions

Access to information owned by the University is generally broadly consistent with the concept of academic freedom and the open nature of the institution. However, there are types of information where access must be restricted and caution in handling and storing the information is necessary. 

This policy is not intended to replace or supersede the specific policies identified below, and any conflicts will be controlled by the specific policies and not this one. 

High Risk Information

The disclosure and use of the following types of information is restricted by law. See the specific policies referenced for a more specific definition of each type of information and of the rules and procedures concerning its use: 

• Social Security Numbers (SSN)
• Patient Protected Health Information (HIPAA)
• Student Information (FERPA)¹
• Financial Account, Credit and Debit Card Information
• Employee Personnel Records: Policy 108 and Policy 404

Access and Use: High Risk Information must be stored, used and disclosed to others only on a need to know basis to permit the individual faculty or staff member to perform their University functions for which the information was acquired and for which it is maintained. Access to High Risk Information must be carefully safe-guarded.

Protection of High Risk Information from disclosure to or unauthorized access by anyone who does not have a legitimate need to access the information to comply with requirements of the law or to carry on necessary University functions is a primary responsibility of the Custodian. 

Alternatives to using High Risk Information should be identified and used whenever possible. 

Disclosure of High Risk Information to a third party agent or vendor is permitted only if the agent or vendor assumes a legally binding obligation to safe-guard the use and disclosure of the information. The electronic exchange of High Risk Information outside of the University of Rochester must have proper approval. In addition, 

• The Information Security Office must be consulted to ensure appropriate security controls are employed (See contact list below). 
• Corporate Purchasing must be consulted to ensure appropriate contract language is incorporated into any agreement. 

Contact the Office of Counsel for appropriate contractual language. 

Storage and Protection: High Risk Information in paper form must be stored in locked or otherwise secured areas when not in active use. High Risk Information in electronic form must be stored in secure designated data centers or, if authorized to be stored elsewhere, only in encrypted (or similarly protected) form. It must not be stored on desktop, laptop or other portable devices or media without encryption or similar protection. Contact Information Technology (University IT or ISD) or a Privacy Officer for advice and assistance. 

Transmission: Reports and communications should not include High Risk Information unless essential to perform the function for which the communication is made. Transmission of High Risk Data must be by secure methods. If High Risk Data is transmitted by e-mail or other electronic transmission, it must be encrypted or otherwise adequately protected. 

Contact Information Technology (University IT or ISD) or a Privacy Officer for advice and assistance. 

Destruction: When a record containing High Risk Information is no longer needed, it must be disposed of in a manner that makes the High Risk Data no longer readable or recoverable. Destruction of paper records containing High Risk Data normally should be accomplished by shredding. Destruction of electronic records containing High Risk Data begins with deleting the data from its storage location. Contact Information Technology (University IT or ISD) or a Privacy Officer for additional advice and assistance. 

Specific Rules for FERPA: Student information is governed by FERPA and the University policies implementing FERPA. Because of the extensive educational activities of the University, many people within the University community have a legitimate need to access and transmit student records. The confidentiality of student records must be safe guarded, but the strict rules for storage and destruction of High Risk Information set forth in this Policy are not always appropriate for student records. See the specific University policies on FERPA referenced above or contact the Registrar for more specific guidance. 

Reporting Unauthorized Disclosure of High Risk Information: Prompt reporting of unauthorized disclosure of High Risk Information is essential for the University to meets its obligations under law, regulation, and contract. The University will not take disciplinary action against any person solely because of his or her good faith reporting of a disclosure. Individuals who report violations of this Policy will be protected from retaliation resulting from providing information. Individuals who report violations of this Policy to the Hotline can remain anonymous. 

Immediately report any suspected unauthorized disclosure of or access to an SSN or material containing SSNs to any of the following: 

Confidential Information

Information can be sensitive or proprietary and the University users may have reasons to treat it as confidential. Confidential Information includes many of the communications or records of the Board of Trustees and senior administrators. It includes faculty research or writing before publication or during the intellectual property protection process. It includes information that the University has agreed to hold confidential under a contract with another party. There are other examples. 

Restriction of Information as Moderate Risk: If a faculty or staff member is responsible for information that is sensitive, proprietary or otherwise in need of confidential treatment, the individual should clearly label the information “Moderate Risk.” The word Moderate Risk should be placed prominently on the information in a form appropriate to the medium in which it exists with an understanding that the purpose of the label should be to warn others clearly that this information is Moderate Risk and should be treated accordingly. 

Storage, Transmission, Access and Destruction: The rules set forth in the section dealing with High Risk Information should be applied to all Moderate Risk Information. 

Low Risk University Use Only Information

Much information necessary for people to perform their work at the University is properly available to others at the University, but is not appropriate to be known by the general public. Information for Low Risk Internal University Use Only is protected behind electronic firewalls or in private paper files in secured offices and is not accessible by the public at large. This is appropriate and will continue. Common sense and good practice dictate that this information remains accessible on a need to know basis by employees and sometimes by students, but not accessible by the media or outsiders. Examples are: budgets, strategic or unit business plans, proposals, contracts, many policies and procedures, correspondence, grant related documents, financial records, etc. 

IV. Public Information 

Public information is information that is available to all members of the University community and may be made available to the general public. The University reserves the right to control the content and format of Public information. Examples include the University’s audited financial statements, schedule of classes, approved census facts and the information on the public University website. 

Enforcement

Violations of this Policy will be handled under normal University disciplinary procedures applicable to the relevant persons or departments. The University may suspend, block or restrict access to information and network resources when it reasonably appears necessary to do so in order to protect the integrity, security, or functionality of University resources or to protect the University from liability. The University routinely monitors the use of Information Technology Resources to assure the integrity and security of University resources. The University may refer suspected violations of applicable law to appropriate law enforcement agencies. 

Violations of this Policy can result in disciplinary action up to and including separation from the University and/or exclusion from University programs, facilities and privileges. Violations of law can lead to fines, injunctions and personal liability. 

Approval and Review

To continue to support University technology resources, further Policy and procedural development is planned. Future Policy revision will likely include additional material concerning information security, data classification and network administration. The Policy will be reviewed and may be changed. 

Approved by President Joel Seligman on December 12, 2006 

Revision approved on January 7, 2009 

Revision approved on March 17, 2011 

Revision approved on July 25, 2014 

Revision approved on January 17, 2019 

Questions

If you have questions, call or email: