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[null,null,null,null,null,null,null,null,"Healthcare and Public Health Sector"]
[null,null,null,null,null,null,null,null,"Rapid Infrastructure Survey Tool"]
[null,null,null,null,null,null,null,null,"Vulnerability and Resilience Module"]
[]
[null,null,null,null,null,null,null,null,"Version 1.1"]
[null,null,null,null,null,null,null,null,"Release Date: Feb. 3, 2017"]
[]
[]
[]
[]
[]
[null,null,null,null,null,null,null,null,"Click button to begin."]
[]
[null,null,null,null,null,null,null,null,"** For best results, this tool should be used with Microsoft Excel version 2013 or later **"]
[]
[null,null,null,null,null,null,null,null,"This tool is the property of the U.S. Department of Health and Human Services."]
[null,null,null,null,null,null,null,null,"Comments and questions can be directed to the Critical Infrastructure Protection (CIP) Office at cip@hhs.gov"]

{"sheet":"MENU","index":1,"n_rows":42,"n_cols":14,"rows_kept":42,"cut":false,"hidden":true,"merged":[[3,1,3,14]]}
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[]
[null,"RIST-V Menu"]
[null,"This page lists each section of the RIST-V, and updates to reflect progress made within each section as the survey is completed. You may proceed directly to any section by clicking on the section heading. \nOtherwise, click Next at the bottom of the page to start from the beginning."]
[null,"Return to this page at any time by clicking the Menu button at the top of each screen."]
[]
[null,null,null,null,null,null,null,null,null,"Questions Completed",null,null,null,"Total Completed"]
[null,null,null,1,"Facility/Asset Characterization",null,null,null,null,{"$f":"Scoring!$M$3&\"/\"&Scoring!$L$3","v":"0/7"},{"$f":"\"(\"&Scoring!N3&\"%)\"","v":"(0%)"},null,null,{"$f":"PROGRESS","v":0}]
[null,null,0,1.1000000000000001,"General Characterization",null,null,null,null,{"$f":"OFFSET(Scoring!$L$9, 0, C9*9)\n&\"/\"&\nOFFSET(Scoring!$K$9, 0, C9*9)","v":"0/7"},{"$f":"\"(\"&\nOFFSET(Scoring!$M$9, 0, C9*9)\n&\"%)\"","v":"(0%)"}]
[]
[null,null,null,2,"Resilience Management Profile",null,null,null,null,{"$f":"Scoring!V3&\"/\"&Scoring!U3","v":"0/77"},{"$f":"\"(\"&Scoring!W3&\"%)\"","v":"(0%)"}]
[null,null,1,2.1,"Business Continuity",null,null,null,null,{"$f":"OFFSET(Scoring!$L$9, 0, C12*9)\n&\"/\"&\nOFFSET(Scoring!$K$9, 0, C12*9)","v":"0/13"},{"$f":"\"(\"&\nOFFSET(Scoring!$M$9, 0, C12*9)\n&\"%)\"","v":"(0%)"}]
[null,null,2,2.2000000000000002,"Emergency Management",null,null,null,null,{"$f":"OFFSET(Scoring!$L$9, 0, C13*9)\n&\"/\"&\nOFFSET(Scoring!$K$9, 0, C13*9)","v":"0/50"},{"$f":"\"(\"&\nOFFSET(Scoring!$M$9, 0, C13*9)\n&\"%)\"","v":"(0%)"}]
[null,null,3,2.2999999999999998,"Information Sharing",null,null,null,null,{"$f":"OFFSET(Scoring!$L$9, 0, C14*9)\n&\"/\"&\nOFFSET(Scoring!$K$9, 0, C14*9)","v":"0/5"},{"$f":"\"(\"&\nOFFSET(Scoring!$M$9, 0, C14*9)\n&\"%)\"","v":"(0%)"}]
[null,null,4,2.4,"Climate Change",null,null,null,null,{"$f":"OFFSET(Scoring!$L$9, 0, C15*9)\n&\"/\"&\nOFFSET(Scoring!$K$9, 0, C15*9)","v":"0/9"},{"$f":"\"(\"&\nOFFSET(Scoring!$M$9, 0, C15*9)\n&\"%)\"","v":"(0%)"}]
[]
[null,null,null,3,"Physical Security Management Profile",null,null,null,null,{"$f":"Scoring!BF3&\"/\"&Scoring!BE3","v":"0/99"},{"$f":"\"(\"&Scoring!BG3&\"%)\"","v":"(0%)"}]
[null,null,5,3.1,"Physical Security Organization, Policies, and Plans",null,null,null,null,{"$f":"OFFSET(Scoring!$L$9, 0, C18*9)\n&\"/\"&\nOFFSET(Scoring!$K$9, 0, C18*9)","v":"0/12"},{"$f":"\"(\"&\nOFFSET(Scoring!$M$9, 0, C18*9)\n&\"%)\"","v":"(0%)"}]
[null,null,6,3.2,"Personnel Surety",null,null,null,null,{"$f":"OFFSET(Scoring!$L$9, 0, C19*9)\n&\"/\"&\nOFFSET(Scoring!$K$9, 0, C19*9)","v":"0/7"},{"$f":"\"(\"&\nOFFSET(Scoring!$M$9, 0, C19*9)\n&\"%)\"","v":"(0%)"}]
[null,null,7,3.3,"Security Training",null,null,null,null,{"$f":"OFFSET(Scoring!$L$9, 0, C20*9)\n&\"/\"&\nOFFSET(Scoring!$K$9, 0, C20*9)","v":"0/8"},{"$f":"\"(\"&\nOFFSET(Scoring!$M$9, 0, C20*9)\n&\"%)\"","v":"(0%)"}]
[null,null,8,3.4,"Security Force Profile",null,null,null,null,{"$f":"OFFSET(Scoring!$L$9, 0, C21*9)\n&\"/\"&\nOFFSET(Scoring!$K$9, 0, C21*9)","v":"0/18"},{"$f":"\"(\"&\nOFFSET(Scoring!$M$9, 0, C21*9)\n&\"%)\"","v":"(0%)"}]
[null,null,9,3.5,"Physical Access Control",null,null,null,null,{"$f":"OFFSET(Scoring!$L$9, 0, C22*9)\n&\"/\"&\nOFFSET(Scoring!$K$9, 0, C22*9)","v":"0/26"},{"$f":"\"(\"&\nOFFSET(Scoring!$M$9, 0, C22*9)\n&\"%)\"","v":"(0%)"}]
[null,null,10,3.6,"Lighting, Surveillance, and Intrusion Detection",null,null,null,null,{"$f":"OFFSET(Scoring!$L$9, 0, C23*9)\n&\"/\"&\nOFFSET(Scoring!$K$9, 0, C23*9)","v":"0/17"},{"$f":"\"(\"&\nOFFSET(Scoring!$M$9, 0, C23*9)\n&\"%)\"","v":"(0%)"}]
[null,null,11,3.7,"Badging and Internal Security",null,null,null,null,{"$f":"OFFSET(Scoring!$L$9, 0, C24*9)\n&\"/\"&\nOFFSET(Scoring!$K$9, 0, C24*9)","v":"0/11"},{"$f":"\"(\"&\nOFFSET(Scoring!$M$9, 0, C24*9)\n&\"%)\"","v":"(0%)"}]
[]
[null,null,null,4,"Critical Dependencies",null,null,null,null,{"$f":"Scoring!DQ3&\"/\"&Scoring!DP3","v":"0/93"},{"$f":"\"(\"&Scoring!DR3&\"%)\"","v":"(0%)"}]
[null,null,12,4.0999999999999996,"General Dependencies",null,null,null,null,{"$f":"OFFSET(Scoring!$L$9, 0, C27*9)\n&\"/\"&\nOFFSET(Scoring!$K$9, 0, C27*9)","v":"0/11"},{"$f":"\"(\"&\nOFFSET(Scoring!$M$9, 0, C27*9)\n&\"%)\"","v":"(0%)"}]
[null,null,13,4.2,"Information Technology (IT)",null,null,null,null,{"$f":"OFFSET(Scoring!$L$9, 0, C28*9)\n&\"/\"&\nOFFSET(Scoring!$K$9, 0, C28*9)","v":"0/15"},{"$f":"\"(\"&\nOFFSET(Scoring!$M$9, 0, C28*9)\n&\"%)\"","v":"(0%)"}]
[null,null,14,4.3,"Electricity",null,null,null,null,{"$f":"OFFSET(Scoring!$L$9, 0, C29*9)\n&\"/\"&\nOFFSET(Scoring!$K$9, 0, C29*9)","v":"0/14"},{"$f":"\"(\"&\nOFFSET(Scoring!$M$9, 0, C29*9)\n&\"%)\"","v":"(0%)"}]
[null,null,15,4.4000000000000004,"Natural Gas",null,null,null,null,{"$f":"OFFSET(Scoring!$L$9, 0, C30*9)\n&\"/\"&\nOFFSET(Scoring!$K$9, 0, C30*9)","v":"0/9"},{"$f":"\"(\"&\nOFFSET(Scoring!$M$9, 0, C30*9)\n&\"%)\"","v":"(0%)"}]
[null,null,16,4.5,"Water",null,null,null,null,{"$f":"OFFSET(Scoring!$L$9, 0, C31*9)\n&\"/\"&\nOFFSET(Scoring!$K$9, 0, C31*9)","v":"0/8"},{"$f":"\"(\"&\nOFFSET(Scoring!$M$9, 0, C31*9)\n&\"%)\"","v":"(0%)"}]
[null,null,17,4.5999999999999996,"Wastewater and Waste Disposal",null,null,null,null,{"$f":"OFFSET(Scoring!$L$9, 0, C32*9)\n&\"/\"&\nOFFSET(Scoring!$K$9, 0, C32*9)","v":"0/8"},{"$f":"\"(\"&\nOFFSET(Scoring!$M$9, 0, C32*9)\n&\"%)\"","v":"(0%)"}]
[null,null,18,4.7,"Communications",null,null,null,null,{"$f":"OFFSET(Scoring!$L$9, 0, C33*9)\n&\"/\"&\nOFFSET(Scoring!$K$9, 0, C33*9)","v":"0/6"},{"$f":"\"(\"&\nOFFSET(Scoring!$M$9, 0, C33*9)\n&\"%)\"","v":"(0%)"}]
[null,null,19,4.8,"Transportation",null,null,null,null,{"$f":"OFFSET(Scoring!$L$9, 0, C34*9)\n&\"/\"&\nOFFSET(Scoring!$K$9, 0, C34*9)","v":"0/5"},{"$f":"\"(\"&\nOFFSET(Scoring!$M$9, 0, C34*9)\n&\"%)\"","v":"(0%)"}]
[null,null,20,4.9000000000000004,"Critical Products",null,null,null,null,{"$f":"OFFSET(Scoring!$L$9, 0, C35*9)\n&\"/\"&\nOFFSET(Scoring!$K$9, 0, C35*9)","v":"0/17"},{"$f":"\"(\"&\nOFFSET(Scoring!$M$9, 0, C35*9)\n&\"%)\"","v":"(0%)"}]
[]
[null,null,null,5,"Cybersecurity Management",null,null,null,null,{"$f":"Scoring!GT3&\"/\"&Scoring!GS3","v":"0/104"},{"$f":"\"(\"&Scoring!GU3&\"%)\"","v":"(0%)"}]
[null,null,21,5.0999999999999996,"Identify",null,null,null,null,{"$f":"OFFSET(Scoring!$L$9, 0, C38*9)\n&\"/\"&\nOFFSET(Scoring!$K$9, 0, C38*9)","v":"0/24"},{"$f":"\"(\"&\nOFFSET(Scoring!$M$9, 0, C38*9)\n&\"%)\"","v":"(0%)"}]
[null,null,22,5.2,"Protect",null,null,null,null,{"$f":"OFFSET(Scoring!$L$9, 0, C39*9)\n&\"/\"&\nOFFSET(Scoring!$K$9, 0, C39*9)","v":"0/40"},{"$f":"\"(\"&\nOFFSET(Scoring!$M$9, 0, C39*9)\n&\"%)\"","v":"(0%)"}]
[null,null,23,5.3,"Detect",null,null,null,null,{"$f":"OFFSET(Scoring!$L$9, 0, C40*9)\n&\"/\"&\nOFFSET(Scoring!$K$9, 0, C40*9)","v":"0/17"},{"$f":"\"(\"&\nOFFSET(Scoring!$M$9, 0, C40*9)\n&\"%)\"","v":"(0%)"}]
[null,null,24,5.4,"Response",null,null,null,null,{"$f":"OFFSET(Scoring!$L$9, 0, C41*9)\n&\"/\"&\nOFFSET(Scoring!$K$9, 0, C41*9)","v":"0/18"},{"$f":"\"(\"&\nOFFSET(Scoring!$M$9, 0, C41*9)\n&\"%)\"","v":"(0%)"}]
[null,null,25,5.5,"Recovery",null,null,null,null,{"$f":"OFFSET(Scoring!$L$9, 0, C42*9)\n&\"/\"&\nOFFSET(Scoring!$K$9, 0, C42*9)","v":"0/5"},{"$f":"\"(\"&\nOFFSET(Scoring!$M$9, 0, C42*9)\n&\"%)\"","v":"(0%)"}]

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[]
[1,"Facility/Asset Characterization"]
[]
[null,1.1000000000000001,null,"General Characterization"]
[]
[]
[null,"1.1.1    ",{"$f":"IF(ISBLANK(D8)=TRUE,0,1)","v":0},"Provide an identifier (e.g., name) for the facility"]
[null,null,{"$f":"D8","v":0}]
[]
[null,"1.1.2",{"$f":"IF(ISBLANK(D11)=TRUE,0,1)","v":0},"Select the subsector below that best characterizes the facility."]
[null,null,{"$f":"D11","v":0}]
[null,null,null,"Direct Patient Care"]
[null,null,null,"Laboratories"]
[null,null,null,"Blood"]
[null,null,null,"Pharmaceuticals"]
[null,null,null,"Medical Materials"]
[null,null,null,"Health Information Technology (IT)"]
[null,null,null,"Health Plans and Payers"]
[null,null,null,"Mass Fatality Management Services"]
[null,null,null,"Public Health"]
[null,null,null,"Federal Response and Program Offices"]
[]
[null,"1.1.3",{"$f":"IF(ISBLANK(D24)=TRUE,0,1)","v":0},"What key services does the facility provide?"]
[]
[]
[null,"1.1.4",0,"Is the facility co-located with an open access academic institution?"]
[]
[]
[]
[null,"1.1.5",0,"Does the facility house or is it co-located with a Bio Safety Lab (BSL)-designated facility and/or select agent laboratory?"]
[]
[]
[]
[null,"1.1.6",{"$f":"IF(C39=TRUE,99,COUNTIF(C36:C38,TRUE))","v":0},"Does the facility house any of the following hazardous substances?"]
[null,null,null,"Check all that apply."]
[null,null,false,"Radioactive materials"]
[null,null,false,"Highly hazardous chemicals"]
[null,null,false,"Narcotics and/or other controlled substances?"]
[null,null,false,"None of the above"]
[]
[null,"1.1.7",{"$f":"IF(C46=TRUE,99,COUNTIF(C43:C45,TRUE))","v":0},"Does the facility include the following sensitive patient care areas?"]
[null,null,null,"Check all that apply."]
[null,null,false,"Radiopharmacies"]
[null,null,false,"Nuclear medicine facilities"]
[null,null,false,"Radiation treatment areas"]
[null,null,false,"None of the above"]

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[2,"Resilience Management Profile"]
[]
[null,2.1,null,"Business Continuity (1 of 2)"]
[]
[]
[null,"2.1.1    ",0,"Is there a designated manager/department in charge of business continuity?"]
[]
[]
[]
[null,"2.1.2",0,"Does the facility have a written business continuity plan?"]
[]
[]
[]
[null,null,0,"2.1.2.1  ","Does the business continuity plan identify mission essential functions and mission critical personnel?"]
[]
[]
[]
[null,null,0,"2.1.2.2  ","Does the business continuity plan include both physical and cyber assets and systems critical to the mission?"]
[]
[]
[]
[null,null,0,"2.1.2.3  ","Does the business continuity plan address external supply chain security and continuity?"]
[]
[]
[]
[null,null,0,"2.1.2.4  ","Does the business continuity plan provide for the alert and recall of essential personnel as well as for extended operations during a local or regional disaster?"]
[]
[]
[]
[null,null,0,"2.1.2.5  ","Are personnel trained on the business continuity plan?"]
[]
[]
[]
[null,null,0,"2.1.2.6  ","Is the business continuity plan exercised at least once a year?"]
[]
[]
[]
[null,null,0,"2.1.2.7  ","Does the business continuity plan define an acceptable recovery time for critical functions?"]

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[]
[2,"Resilience Management Profile"]
[]
[null,2.1,null,"Business Continuity (2 of 2)"]
[]
[]
[null,"2.1.3    ",0,"Are agreements in place with partners, vendors, and other service providers for the provision of services to ensure continuity of essential functions during emergency/disaster situations?"]
[]
[]
[]
[null,"2.1.4    ",0,"Are agreements in place with other similar facilities that can provide required services in the event of a critical service disruption to your facility or critical satellite operation?"]
[]
[]
[]
[null,"2.1.5    ",0,"Have the agreements referenced in the above two questions (2.1.3 and 2.1.4) been assessed/tested to ensure their validity in major disaster scenarios where multiple entities may be relying on the same partners, vendors, and other service providers for similar commodities and services?"]
[]
[]
[]
[null,"2.1.6    ",0,"Does management have a purchase card to use, or are prior arrangements made to invoice items purchased locally during an emergency situation?"]

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[]
[2,"Resilience Management Profile"]
[]
[null,2.2000000000000002,null,"Emergency Management (1 of 6)"]
[]
[]
[null,"2.2.1",0,"Is the facility a Joint Commission accredited healthcare facility?"]
[]
[]
[]
[null,"2.2.2",0,"Is the facility compliant with all Centers for Medicare and Medicaid Services (CMS) Emergency Preparedness requirements for the Provider Type it represents?"]
[]
[]
[]
[null,"2.2.3",0,"Is there a designated manager/department in charge of emergency management operations?"]
[]
[]
[]
[null,null,0,"2.2.3.1","Is the designated emergency manager professionally certified in the emergency management field?"]
[]
[]
[]
[null,"2.2.4",0,"Does the facility have a written Emergency Operations Plan (EOP), including triggers for the alert, warning, and activation of managers and staff with emergency management duties? "]
[]
[]
[]
[null,null,0,"2.2.4.1","Is the EOP based on an all-hazards risk assessment?"]
[]
[]
[]
[null,null,0,"2.2.4.2","Is the EOP developed with the assistance of fire, safety, security, and other discipline-specific professionals?"]

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[]
[2,"Resilience Management Profile"]
[]
[null,2.2000000000000002,null,"Emergency Management (2 of 6)"]
[]
[]
[null,null,{"$f":"IF(C20=TRUE,99,COUNTIF(C9:C19,TRUE))","v":0},"2.2.4.3","Does the facility's EOP cover the following response actions?"]
[null,null,null,null,"Check all that apply."]
[null,null,false,null,"Providing for crisis standards of care/critical services (including threshold criteria for switching to crisis standards of care)"]
[null,null,false,null,"Maintaining or expanding services during emergencies"]
[null,null,false,null,"Conserving resources during emergencies"]
[null,null,false,null,"Curtailing services during emergencies"]
[null,null,false,null,"Supplementing resources from outside the local community"]
[null,null,false,null,"Closing the facility to new patients/customers"]
[null,null,false,null,"Staged evacuation"]
[null,null,false,null,"Shelter in place"]
[null,null,false,null,"Scenario-based surge requirements"]
[null,null,false,null,"Transportation/transfer of patients to alternate care locations"]
[null,null,false,null,"Tracking of on-duty staff & sheltered patients/residents during and in the aftermath of an emergency"]
[null,null,false,null,"None of the above"]
[]
[null,null,{"$f":"IF(C42=TRUE,99,COUNTIF(C24:C41,TRUE))","v":0},"2.2.4.4","Does the EOP:"]
[null,null,null,null,"Check all that apply."]
[null,null,false,null,"Contain the names and contact information of the manager/department in charge of emergency management operations?"]
[null,null,false,null,"Describe the back-up systems (including power, water, communications, HVAC, etc.) and the recovery strategies and actions designed to help restore the systems that are critical to providing care, treatment, and other critical customer services in the aftermath of an emergency?"]
[null,null,false,null,"Prescribe protocols or refer to separate policies and procedures that address the provision of alternative sources of energy to maintain: 1) temperatures to protect patient/staff health and safety and for the safe and sanitary storage of provisions; 2) emergency lighting; and 3) fire detection, extinguishing, and alarm systems?"]
[null,null,false,null,"Contain protocols for responding to two or more simultaneous emergencies/disasters with second and third order cascading effects?"]
[null,null,false,null,"Identify alternative sites for care, treatment, and other services that meet the needs of its patients/customers during emergencies?"]
[null,null,false,null,"Establish an Incident Command System based on recognized national and healthcare sector emergency management standards?"]
[null,null,false,null,"Is the facility’s incident command structure integrated into and consistent with the local community incident command structure?"]
[null,null,false,null,"Include detailed actions to be undertaken by managers, staff, contractors, and volunteers in response to various emergency situations, with detailed protocols for all-hazards emergencies included as annexes?"]
[null,null,false,null,"Detail how the facility will manage the activities required as part of patient scheduling, triage, assessment, treatment, admission, transfer, discharge, follow-up and clinical information management, as well as activities associated with the continuity of other critical functions/customer support services during an emergency?"]
[null,null,false,null,"Describe how the facility will manage a potential increase in demand for clinical services for vulnerable populations served, such as patients who are pediatric, geriatric, disabled, or have serious chronic conditions or addictions?"]
[null,null,false,null,"Include detailed reporting and communications protocols and response actions by incident type? "]
[null,null,false,null,"Provide protocols for the response to emergencies posing unique safety or environmental hazards in the context of the facility or surrounding area?"]
[null,null,false,null,"Describe how the facility will provide for radioactive, biological, and chemical isolation and decontamination, if required?"]
[null,null,false,null,"Provide for integration with corresponding municipal and/or county EOPs?"]
[null,null,false,null,"Establish response times for external partner agencies by incident type?"]
[null,null,false,null,"Describe how the facility will manage staff support needs (i.e. housing, transportation, incident stress debriefing, etc.) and staff family support needs (i.e. child care, elder care, pet care, communication, etc.)?"]
[null,null,false,null,"Describe how the facility will identify licensed independent practitioners, staff, and authorized volunteers during emergencies?"]
[null,null,false,null,"Identify the process to be used for credentialing and authorized re-entry of critical personnel in the aftermath of a disaster where access may be limited?"]
[null,null,false,null,"None of the above."]
[]
[null,null,0,"2.2.4.5","Does the EOP contain a Communication Annex or linkages to a separate Emergency Preparedness (EP) Communications Plan that describes how and under what circumstances the facility will communicate information about patients to third parties (such as other health care organizations, the city/county/state health department, local law enforcement, FBI, etc.)? "]
[]
[]
[]
[null,null,{"$f":"IF(C55=TRUE,99,COUNTIF(C50:C54,TRUE))","v":0},null,"2.2.4.5.1","Does the Communications Annex or separate EP Communications Plan:"]
[null,null,null,null,"Check all that apply."]
[null,null,false,null,"Contain contact information for external first responder and emergency management agencies?"]
[null,null,false,null,"Contain contact protocols for coordination and communication with external first responder and emergency management agencies?"]
[null,null,false,null,"Include contact information for other hospitals and CAHs?"]
[null,null,false,null,"Specify a method for sharing information and medical documentation for patients?"]
[null,null,false,null,"Specify a protocol for releasing patient information consistent with the HIPAA Privacy Rule in the event of a facility evacuation?"]
[null,null,false,null,"None of the above."]
[]
[null,null,0,null,"2.2.4.5.2","Is the Communications Annex or separate EP Communications Plan compliant with Federal and State laws?"]
[]
[]
[]
[null,null,{"$f":"IF(C70=TRUE,99,COUNTIF(C63:C69,TRUE))","v":0},"2.2.4.6","Does the facility's EOP cover the following event types, at a minimum?"]
[null,null,null,null,"Check all that apply."]
[null,null,false,null,"Fire emergencies"]
[null,null,false,null,"Power Failures"]
[null,null,false,null,"Care-related Emergencies"]
[null,null,false,null,"Active shooter and other malicious actor types"]
[null,null,false,null,"Water Supply Disruption"]
[null,null,false,null,"Natural disasters"]
[null,null,false,null,"HAZMAT Releases"]
[null,null,false,null,"None of the above."]

{"sheet":"2.2.c","index":7,"n_rows":61,"n_cols":6,"rows_kept":61,"cut":false,"hidden":true,"merged":[[52,5,52,14],[32,5,32,14],[36,5,36,14],[40,5,40,14],[44,5,44,14],[6,4,6,14],[14,4,14,14],[22,4,22,14],[26,4,26,14],[48,5,48,14]]}
[]
[2,"Resilience Management Profile"]
[]
[null,2.2000000000000002,null,"Emergency Management (3 of 6)"]
[]
[]
[null,null,0,"2.2.4.7","Are supplemental policies and procedures developed and implemented based on the requirements identified in the emergency plan, risk assessment, and separate EP communication plan?"]
[]
[]
[]
[null,null,0,null,"2.2.4.7.1","Are such policies and procedures reviewed/updated at least annually?"]
[]
[]
[]
[null,null,0,"2.2.4.8","Are managers, employees, contractor staff, and volunteers trained on the EOP, EP Communications Plan and supporting policies and procedures, including their roles and responsibilities (i.e., communications, resources and assets, safety and security, utilities, and patient management, etc.), chain of command, reporting instructions, etc., in the context of specific types of incidents?"]
[]
[]
[]
[null,null,0,null,"2.2.4.8.1","Is such training provided at least annually?"]
[]
[]
[]
[null,null,0,"2.2.4.9","Are managers, employees, contractor staff, and volunteers sufficiently cross-trained to enable the performance of specialized duties and supporting protocols identified in the EOP?"]
[]
[]
[]
[null,null,0,"2.2.4.10","How frequently is the EOP exercised against the most relevant hazards identified through the risk assessment process?"]
[null,null,null,null,"At least semiannually (twice per year)"]
[null,null,null,null,"Annually (once per year)"]
[null,null,null,null,"Biannually (every two years)"]
[null,null,null,null,"EOP is not exercised"]
[]
[null,null,0,0,"2.2.4.10.1","Does the exercise of the EOP involve community participation, including participation from local first responder agencies and EOCs?"]
[]
[]
[]
[null,null,0,0,"2.2.4.10.2","Does the exercise of the EOP include an escalating event in which the local community is unable to support the facility?"]
[]
[]
[]
[null,null,0,0,"2.2.4.10.3","Does the facility’s exercise program align to DHS Homeland Security Exercise and Evaluation Program (HSEEP) guidance?"]
[]
[]
[]
[null,null,0,0,"2.2.4.10.4","Does the exercise of the EOP involve the partners and/or private companies that hold supply agreements for dependencies?"]
[]
[]
[]
[null,null,0,0,"2.2.4.10.5","Does the facility’s exercise program simulate impacts to critical functions and services and the timely restoration thereof?"]
[]
[]
[]
[null,null,{"$f":"IF(C61=TRUE,99,COUNTIF(C55:C60,TRUE))","v":0},null,"2.2.4.10.6","Does the facility’s exercise program allow the facility to evaluate its handling of the following internal and external partner organization components?"]
[null,null,null,null,null,"Check all that apply."]
[null,null,false,null,null,"Communications "]
[null,null,false,null,null,"Resources and assets"]
[null,null,false,null,null,"Security"]
[null,null,false,null,null,"Staff"]
[null,null,false,null,null,"Utilities"]
[null,null,false,null,null,"Patients"]
[null,null,false,null,null,"None of the above."]

{"sheet":"2.2.d","index":8,"n_rows":18,"n_cols":5,"rows_kept":18,"cut":false,"hidden":true,"merged":[[6,4,6,14]]}
[]
[2,"Resilience Management Profile"]
[]
[null,2.2000000000000002,null,"Emergency Management (4 of 6)"]
[]
[]
[null,null,0,"2.2.4.11","Does the facility modify its EOP based on its evaluations of emergency response exercises and responses to actual emergencies?"]
[]
[]
[]
[null,null,0,"2.2.4.12","How frequently is the EOP reviewed, revised, and/or updated?"]
[null,null,null,null,"At least semiannually (twice per year)"]
[null,null,null,null,"Annually (once per year)"]
[null,null,null,null,"Biannually (every two years)"]
[null,null,null,null,"EOP is not reviewed, revised, or updated"]
[]
[null,null,0,"2.2.4.13","Is the EOP reviewed, revised, or updated in response to emergency events experienced by others?"]
[null,null,null,null,"For example, lessons learned after a televised active shooter event."]

{"sheet":"2.2.e","index":9,"n_rows":47,"n_cols":5,"rows_kept":47,"cut":false,"hidden":true,"merged":[[34,4,34,14],[6,3,6,14],[10,3,10,14],[14,3,14,14],[18,3,18,14],[26,3,26,14],[30,3,30,14]]}
[]
[2,"Resilience Management Profile"]
[]
[null,2.2000000000000002,null,"Emergency Management (5 of 6)"]
[]
[]
[null,"2.2.5",0,"Does the facility conduct an annual review/prioritization of its risks, hazards, and potential emergencies as defined through a formal risk assessment process?"]
[]
[]
[]
[null,"2.2.6",0,"Does the facility have protocols for coordination with relevant incident management structures at the Federal, state, local, tribal, and territorial government levels?"]
[]
[]
[]
[null,"2.2.7",0,"Does the facility communicate its needs and vulnerabilities to community emergency response agencies and identify the community’s capability to meet its needs?"]
[]
[]
[]
[null,"2.2.8",0,"Are Memoranda of Agreement (MOAs) in place specifying the type of support to be provided by local first responder and emergency management agencies, as well as the conditions under which such support can be expected? "]
[]
[]
[]
[null,null,0,"2.2.8.1","If so, have these agreements been tested/validated through exercises and other activities?"]
[]
[]
[]
[null,"2.2.9",0,"Are MOAs in place specifying the type of support that can be provided by other local/regional and/or coalition healthcare facilities, as well as the conditions under which such support can be expected?"]
[]
[]
[]
[null,"2.2.10",0,"Is the facility a member of a collaborative group designed to support emergency preparedness and response (e.g., a healthcare coalition)? "]
[]
[]
[]
[null,null,0,"2.2.10.1","Does the coalition or group have clearly defined roles and responsibilities for each participating member as related to disaster preparedness, response, and recovery?"]
[]
[]
[]
[null,"2.2.11",{"$f":"IF(C47=TRUE,99,COUNTIF(C41:C46,TRUE))","v":0},"Does the facility have a plan for multi-agency coordination during an incident response, including the following elements?"]
[null,null,null,"Check all that apply."]
[null,null,false,"Representation (physical or virtual) in the local and state Emergency Operations Centers (EOCs)"]
[null,null,false,"Identification of resource needs that require multi-agency coordination "]
[null,null,false,"Protocols to communicate the resource needs of affected healthcare organizations at the outset of any emergency "]
[null,null,false,"Processes to request and activate multi-agency coordination"]
[null,null,false,"Protocols to ensure appropriate multi-agency coordination for emergency response and recovery operations "]
[null,null,false,"Protocols to communicate the operational status of healthcare organizations "]
[null,null,false,"None of the above."]

{"sheet":"2.2.f","index":10,"n_rows":76,"n_cols":9,"rows_kept":76,"cut":false,"hidden":true,"merged":[[60,4,60,14],[64,3,64,14],[70,3,70,14],[9,3,9,14],[15,3,15,14],[23,3,23,14],[33,4,33,14],[48,3,48,14],[56,3,56,14],[30,9,30,14]]}
[]
[2,"Resilience Management Profile"]
[]
[null,2.2000000000000002,null,"Emergency Management (6 of 6)"]
[]
[]
[null,"2.2.12",{"$f":"IF(C14=TRUE,99,COUNTIF(C9:C13,TRUE))","v":0},"Does the facility have processes to effectively obtain and manage resources during incident response, including the following?"]
[null,null,null,"Check all that apply."]
[null,null,false,"Immediately request and obtain resources from available caches"]
[null,null,false,"Retain viable options for resource allocation and sharing that involves the community, private sector, and other stakeholders"]
[null,null,false,"Sharing resources and assets outside of the community"]
[null,null,false,"Request resources from the local, state, and Federal level of emergency operations (e.g., NDMS)"]
[null,null,false,"Monitor quantities of resources and assets"]
[null,null,false,"None of the above."]
[]
[null,"2.2.13",0,"Has the facility de-conflicted emergency needs in agreements with other facilities in the area in anticipation of potential competing needs during major disasters?"]
[]
[]
[]
[null,null,0,"2.2.13.1","Have these de-conflicted agreements and resource sharing arrangements been tested/validated?"]
[]
[]
[]
[null,"2.2.14",{"$f":"IF(C32=TRUE,99,COUNTIF(C26:C31,TRUE))","v":0},"Does the facility have resources and/or supply caches on site that may be needed during an emergency, including, but not limited to: "]
[null,null,null,"Check all that apply."]
[null,null,false,"Personal protective equipment "]
[null,null,false,"Water"]
[null,null,false,"Fuel"]
[null,null,false,"Surgical-related resource and assets "]
[null,null,false,"Medication-related resources and assets"]
[null,null,false,"Other",null,null,null,null,"Specify other caches:"]
[null,null,false,"None of the above."]
[]
[null,null,0,"2.2.14.1","Does the facility keep a documented inventory of the resources and/or supply caches on site for emergency purposes?"]
[]
[]
[]
[null,"2.2.15",{"$f":"IF(C47=TRUE,99,COUNTIF(C40:C46,TRUE))","v":0},"Do emergency communications account for the following:"]
[null,null,null,"Check all that apply."]
[null,null,false,"Internal staff, licensed independent providers or practitioners, contractors, volunteers, etc."]
[null,null,false,"Customers or patients and family members"]
[null,null,false,"Local first responders and emergency management organizations"]
[null,null,false,"Local disaster relief organizations"]
[null,null,false,"Other local/regional health care facilities"]
[null,null,false,"Providers of essential services, alternative care, equipment, and supplies"]
[null,null,false,"The local community in general"]
[null,null,false,"None of the above."]
[]
[null,"2.2.16",0,"Are there mechanisms in place to enable health authorities to identify and control environmental factors that arise during emergencies that are hazardous to human health?"]
[]
[]
[]
[null,"2.2.17",0,"Do procedures and capabilities exist for the safe disposal of medical waste in emergencies?"]
[]
[]
[]
[null,"2.2.18",0,"Does the facility maintain and exercise shelter-in-place and evacuation protocols detailing roles and responsibilities of assigned staff, contractors, and visitors?"]
[]
[]
[]
[null,null,0,"2.2.18.1","Do such protocols address patient/resident and staff tracking, continuous patient care, and patient follow-up during and after evacuation situations?"]
[]
[]
[]
[null,"2.2.19",0,"Does capacity exist for the immediate assessment of structural, nonstructural, and functional safety issues following an incident?"]
[]
[]
[]
[null,"2.2.20",{"$f":"IF(C74=TRUE,99,COUNTIF(C71:C73,TRUE))","v":0},"Does the facility perform post-disaster assessment including the following elements?"]
[null,null,null,"Check all that apply."]
[null,null,false,"Coordination with healthcare organizations to identify immediate operating needs for the delivery of essential healthcare services"]
[null,null,false,"Coordination with partner healthcare organizations to identify possible long-term healthcare recovery priorities "]
[null,null,false,"Processes to communicate healthcare recovery priorities to the local and state agencies responsible for recovery "]
[null,null,false,"None of the above."]
[]
[null,"2.2.21",0,"Is there an emergency management logistics system in place that includes tracking, monitoring, and reporting components?"]

{"sheet":"2.3","index":11,"n_rows":53,"n_cols":7,"rows_kept":53,"cut":false,"hidden":true,"merged":[[11,3,11,14],[6,3,6,14],[34,3,34,14],[40,3,40,14],[46,3,46,14],[52,3,52,14],[37,6,38,13],[43,6,44,13],[49,6,50,13],[30,6,30,13]]}
[]
[2,"Resilience Management Profile"]
[]
[null,2.2999999999999998,null,"Information Sharing"]
[]
[]
[null,"2.3.1 ",{"$f":"IF(C32=TRUE,99,COUNTIF(C9:C31,TRUE))","v":0},"Does the facility receive physical and cyber threat information, security-related bulletins, advisories and/or alerts from external sources?"]
[null,null,null,"Check all that apply."]
[null,null,false,"Department of Homeland Security (DHS)"]
[null,null,false,"Federal Bureau of Investigation (FBI)"]
[null,null,false,"Fusion Center"]
[null,null,false,"Other federal law enforcement (e.g., Federal Protective Service [FPS], Transportation Security Administration [TSA], U.S. Immigration and Customs Enforcement [ICE])"]
[null,null,false,"State Critical Infrastructure Protection (CIP) Coordinator"]
[null,null,false,"Joint Terrorism Task Force (or equivalent)"]
[null,null,false,"State Homeland Security Advisor"]
[null,null,false,"Bureau of Alcohol, Tobacco, Firearms, and Explosives (ATF)"]
[null,null,false,"State emergency management agency"]
[null,null,false,"Information Sharing Analysis Center (ISAC)"]
[null,null,false,"State law enforcement"]
[null,null,false,"Homeland Security Information Network Portal (HSIN)"]
[null,null,false,"Local emergency management agency"]
[null,null,false,"InfraGard"]
[null,null,false,"Local law enforcement"]
[null,null,false,"US Attorney's Office Anti-Terrorism Advisor Council"]
[null,null,false,"Industry group"]
[null,null,false,"Public health agencies"]
[null,null,false,"National Oceanic and Atmospheric Administration (NOAA)"]
[null,null,false,"Corporate law enforcement or security"]
[null,null,false,"United States Geological Survey (USGS)"]
[null,null,false,"Centers for Disease Control and Prevention (CDC)"]
[null,null,false,"Other (specify)"]
[null,null,false,"None"]
[]
[]
[null,"2.3.2",0,"Does the facility share information related to intentional physical and cyber threats and/or security with outside organizations?"]
[]
[null,null,null,null,null,null,"Specify sources below"]
[]
[]
[]
[null,"2.3.2",0,"Does the facility receive information on natural disasters and unintentional manmade/technological hazards from external sources?"]
[]
[null,null,null,null,null,null,"Specify sources below"]
[]
[]
[]
[null,"2.3.2",0,"Does the facility receive vulnerability and/or protective measures recommendations/information, to include physical and cybersecurity-related bulletins, advisories, and/or alerts on technical vulnerabilities, from external sources?"]
[]
[null,null,null,null,null,null,"Specify sources below"]
[]
[]
[]
[null,"2.3.3",0,"Does the facility have protocols for information sharing between healthcare organizations and relevant incident management structures?"]

{"sheet":"2.4","index":12,"n_rows":54,"n_cols":7,"rows_kept":54,"cut":false,"hidden":true,"merged":[[17,3,17,14],[21,3,21,14],[53,3,53,14],[43,6,43,13]]}
[]
[2,"Resilience Management Profile"]
[]
[null,2.4,null,"Climate Change"]
[]
[]
[null,"2.4.1 ",{"$f":"IF(C16=TRUE,99,COUNTIF(C9:C15,TRUE))","v":0},"Which climate change impacts are potential hazards to the facility based on the facility's knowledge and location?"]
[null,null,null,"Check all that apply."]
[null,null,false,"Precipitation (increase or decrease)"]
[null,null,false,"Extreme increases in storms/storm patterns (e.g., winter storms, tornadoes, severe weather, hurricanes)"]
[null,null,false,"Increased potential for flooding or storm surge"]
[null,null,false,"Sea level rise"]
[null,null,false,"Frost increase or decrease"]
[null,null,false,"Ocean acidification increase"]
[null,null,false,"Other"]
[null,null,false,"None"]
[]
[null,"2.4.2",0,"Has a climate change risk assessment been conducted at the facility either formally in response to a larger problem, or informally?"]
[]
[]
[]
[null,"2.4.3",0,"Is there an official or department within the facility designated to serve as the lead for climate change issues/program implementation?"]
[]
[]
[]
[null,"2.4.4",0,"Does the facility have a climate change adaptation plan?"]
[]
[]
[]
[null,null,{"$f":"IF(C39=TRUE,99,COUNTIF(C32:C38,TRUE))","v":0},"2.4.4.1","Which of the following potential impacts are addressed in the climate change adaptation plan?"]
[null,null,null,null,"Check all that apply."]
[null,null,false,null,"Precipitation (increase or decrease)"]
[null,null,false,null,"Extreme increases in storms/storm patterns (e.g., winter storms, tornadoes, severe weather, hurricanes)"]
[null,null,false,null,"Increased potential for flooding or storm surge"]
[null,null,false,null,"Sea level rise"]
[null,null,false,null,"Frost increase or decrease"]
[null,null,false,null,"Ocean acidification increase"]
[null,null,false,null,"Other"]
[null,null,false,null,"None"]
[]
[null,"2.4.5",0,"Does the facility have access to climate data to help inform future planning and decision making?"]
[]
[null,null,null,null,null,null,"Specify the sources below"]
[]
[]
[null,"2.4.6",0,"Are any improvements planned to the construction/design of the facility to reduce the impact of climate change?"]
[]
[]
[]
[null,"2.4.7",0,"Has the facility explored the option/feasibility of diversifying suppliers to prepare for indirect climate change impacts?"]
[]
[]
[]
[null,"2.4.8",0,"Is the facility engaged in climate change planning and risk mitigation activities with appropriate local, state, and/or federal agencies and/or committees?"]

{"sheet":"3.1.a","index":13,"n_rows":34,"n_cols":5,"rows_kept":34,"cut":false,"hidden":true,"merged":[[20,4,20,14]]}
[]
[3,"Physical Security Management Profile"]
[]
[null,3.1,null,"Physical Security Organization, Policies, and Plans (1 of 3)"]
[]
[]
[null,"3.1.1",0,"Is there a designated official/department in charge of physical security management?"]
[]
[]
[]
[null,null,0,"3.1.1.1","If so, is the designated official a full time security professional with appropriate training and certification?"]
[]
[]
[]
[null,"3.1.2",0,"How frequently is a physical security risk assessment conducted?"]
[null,null,null,"At least semiannually (twice per year)"]
[null,null,null,"Annually (once per year)"]
[null,null,null,"Biannually (every two years)"]
[null,null,null,"Physical security risk assessment is not conducted"]
[]
[null,null,0,"3.1.2.1","Does the security risk assessment identify unique characteristics of the facility that may increase target attractiveness or the likelihood of a physical attack or security incident?"]
[]
[]
[]
[null,null,0,"3.1.2.2","How frequently is the physical security risk assessment reviewed?"]
[null,null,null,null,"At least semiannually (twice per year)"]
[null,null,null,null,"Annually (once per year)"]
[null,null,null,null,"Biannually (every two years)"]
[null,null,null,null,"Physical security risk assessment is not conducted"]
[]
[null,null,0,"3.1.2.3","Is the physical security risk assessment reviewed, and by whom?"]
[null,null,null,null,"Reviewed by a committee"]
[null,null,null,null,"Reviewed by an individual"]
[null,null,null,null,"Physical security risk assessment is not reviewed"]

{"sheet":"3.1.b","index":14,"n_rows":13,"n_cols":7,"rows_kept":13,"cut":false,"hidden":true,"merged":[[9,6,10,13]]}
[]
[3,"Physical Security Management Profile"]
[]
[null,3.1,null,"Physical Security Organization, Policies, and Plans (2 of 3)"]
[]
[]
[null,"3.1.3",0,"Does the facility participate in any external security working groups or security forums?"]
[]
[null,null,null,null,null,null,"Specify the forums below"]
[]
[]
[]
[null,"3.1.4",0,"Does the facility have a written physical security plan and/or policy(ies)?"]

{"sheet":"3.1.c","index":15,"n_rows":61,"n_cols":4,"rows_kept":61,"cut":false,"hidden":true,"merged":[[29,3,29,14],[30,3,30,14],[31,3,31,14],[32,3,32,14],[33,3,33,14],[6,3,6,14],[21,3,21,14],[26,3,26,14],[27,3,27,14],[28,3,28,14]]}
[]
[3,"Physical Security Management Profile"]
[]
[null,3.1,null,"Physical Security Organization, Policies, and Plans (3 of 3)"]
[]
[]
[null,"3.1.5",{"$f":"IF(C12=TRUE,99,COUNTIF(C9:C11,TRUE))","v":0},"Does the security plan/policy clearly outline the organizing construct for physical security employed by the facility, including the following:"]
[null,null,null,"Check all that apply."]
[null,null,false,"A layered approach to physical security"]
[null,null,false,"Chain-of-command relationships"]
[null,null,false,"Organizational diagrams"]
[null,null,false,"None of the above"]
[]
[null,"3.1.6",{"$f":"IF(C23=TRUE,99,COUNTIF(C16:C22,TRUE))","v":0},"Does the security plan/policy establish specific security zones, including the following:"]
[null,null,null,"Check all that apply."]
[null,null,false,"General areas accessible to the public at all times"]
[null,null,false,"General areas restricted to the public during non-visiting hours or periods of lesser activity"]
[null,null,false,"Screened public areas"]
[null,null,false,"Staff and accompanied public areas"]
[null,null,false,"General staff-only areas"]
[null,null,false,"Areas for designated staff with the appropriate access privileges"]
[null,null,false,"High-risk areas (e.g. the pharmacy, radiation treatment areas, hazardous materials storage facilities, places where cash is stored, etc.)"]
[null,null,false,"None of the above"]
[]
[null,"3.1.7",{"$f":"IF(C38=TRUE,99,COUNTIF(C27:C37,TRUE))","v":0},"Does the security plan/policy:"]
[null,null,null,"Check all that apply."]
[null,null,false,"Provide for physical separation between general public areas, patient/customer waiting areas, and access-restricted areas?  "]
[null,null,false,"Provide for the separation of loading docks and mail rooms from patient care/customer service and designated critical areas?  "]
[null,null,false,"Clearly define the areas, buildings, and other structures as well as equipment considered critical and/or sensitive and establish priorities for their protection?  "]
[null,null,false,"Identify; provide contact information for; and contain an alert, notification, and assembly protocol for the officials responsible for physical security and facility operations?  "]
[null,null,false,"Contain contact information and protocols for communication and coordination with local law enforcement agencies?"]
[null,null,false,"Contain specific decision criteria as well as specific provisions for facility operations and heightened security measures during periods of elevated security alert?"]
[null,null,false,"Address the unique risks presented by the storage and handling of hazardous materials (i.e. radiological and bio-hazard materials), narcotics, and other controlled materials/substances?  "]
[null,null,false,"Establish appropriate protocols for the receipt, inspection, routing and storage of incoming material, including routine mail and packages, as well as suspicious mail and packages?  "]
[null,null,false,"Address procedures for on-site mail/package/equipment delivery after normal operating hours?"]
[null,null,false,"Contain provisions for reporting and investigating security threats and incidents?"]
[null,null,false,"Contain provisions for documenting security checks and alarm response?"]
[null,null,false,"None of the above."]
[]
[null,"3.1.8",{"$f":"IF(C61=TRUE,99,COUNTIF(C42:C60,TRUE))","v":0},"Are special topic areas, including but not limited to the following, addressed in the security plan/policy?"]
[null,null,null,"Check all that apply."]
[null,null,false,"Weapons"]
[null,null,false,"Use of force"]
[null,null,false,"Child abduction"]
[null,null,false,"Workplace violence"]
[null,null,false,"Patient/visitor hostile actions"]
[null,null,false,"Active shooter"]
[null,null,false,"Hostage situation"]
[null,null,false,"Search and seizure"]
[null,null,false,"Special events"]
[null,null,false,"Media handling"]
[null,null,false,"Security alarm response"]
[null,null,false,"Trespassing"]
[null,null,false,"Patient care and handling"]
[null,null,false,"Prisoners/forensic patients and high profile patients"]
[null,null,false,"Controlled substances"]
[null,null,false,"Biological and radiological materials storage and handling"]
[null,null,false,"Cash transfer operations"]
[null,null,false,"Security of high value equipment and tangible assets"]
[null,null,false,"Other"]
[null,null,false,"None"]

{"sheet":"3.2","index":16,"n_rows":36,"n_cols":4,"rows_kept":36,"cut":false,"hidden":true,"merged":[[31,3,31,14]]}
[]
[3,"Physical Security Management Profile"]
[]
[null,3.2,null,"Personnel Surety"]
[]
[]
[null,"3.2.1",0,"Is there a screening process in place for new hires, including a criminal background check? "]
[]
[]
[]
[null,"3.2.2",{"$f":"IF(C16=TRUE,99,COUNTIF(C13:C15,TRUE))","v":0},"Are security/criminal background checks conducted?"]
[null,null,null,"Check all that apply."]
[null,null,false,"On all employees"]
[null,null,false,"On volunteers"]
[null,null,false,"On contractors/vendors/third party service providers"]
[null,null,false,"None of the above"]
[]
[null,"3.2.3",{"$f":"IF(C22=TRUE,99,COUNTIF(C20:C21,TRUE))","v":0},"Are recurring background checks conducted?"]
[null,null,null,"Check all that apply."]
[null,null,false,"On all employees"]
[null,null,false,"On contractors/vendors/third party service providers"]
[null,null,false,"None of the above"]
[]
[null,"3.2.4",0,"Are audits conducted of contractor/vendor/third party service provider background check processes?"]
[]
[]
[]
[null,"3.2.5",0,"Does the facility have an employee mental/emotional wellness and monitoring program in place?"]
[]
[]
[]
[null,"3.2.6",0,"Does the facility maintain a threat assessment team to assess all people and items that enter the facility to determine if they pose a potential hazard or threat to the facility itself, facility staff and visitors, or the facility's operations?"]
[]
[]
[]
[null,"3.2.7",0,"Does the security plan/policy contain protocols for reporting suspicious activities and/or suspicious behavior in the workplace?"]

{"sheet":"3.3","index":17,"n_rows":35,"n_cols":4,"rows_kept":35,"cut":false,"hidden":true,"merged":[[6,3,6,14],[18,3,18,14],[30,3,30,14],[34,3,34,14]]}
[]
[3,"Physical Security Management Profile"]
[]
[null,3.3,null,"Security Training"]
[]
[]
[null,"3.3.1",0,"Are security staff and facility managers, staff, contractors, and volunteers trained on the security plan/policies, including their roles and responsibilities in response to physical security and specific security-related emergencies?"]
[]
[]
[]
[null,"3.3.2",0,"Does the employee security training program include both an onboarding and a recurring training component?"]
[]
[]
[]
[null,"3.3.3",0,"Does the employee security training program contain an insider threat awareness component?"]
[]
[]
[]
[null,"3.3.4",0,"Is there a comprehensive onboarding and recurring training program in place for security personnel (employees and contractors) tailored to the healthcare environment? "]
[]
[]
[]
[null,"3.3.5",0,"Is employee security training documented in accordance with applicable standards? "]
[]
[]
[]
[null,"3.3.6",0,"Is the security plan exercised at least once a year against the most relevant threat scenarios?"]
[]
[]
[]
[null,"3.3.7",0,"Does the facility conduct threat-specific training (i.e. active shooter, infant abduction, hostile patient, etc.) on a recurring basis as defined in facility policy or other mandates?"]
[]
[]
[]
[null,"3.3.8",0,"Do security exercise activities include the participation of local law enforcement and first responder agencies and other appropriate external organizations?"]

{"sheet":"3.4.a","index":18,"n_rows":13,"n_cols":4,"rows_kept":13,"cut":false,"hidden":true,"merged":[[5,3,5,14],[12,3,12,14]]}
[]
[3,"Physical Security Management Profile"]
[]
[null,3.4,null,"Security Force Profile"]
[]
[null,null,null," A security force is a specially organized and trained group of employees or contractors with specific security duties and responsibilities (e.g. guards). The security force does not include general employees who are trained in security awareness to observe and report security issues in addition to their regular duties."]
[]
[]
[null,"3.4.1",0,"Does the facility have a security force?"]
[]
[]
[]
[null,"3.4.2",0,"If there is no dedicated security force, is there a policy/procedure in place that addresses how facility security functions are performed in the absence of dedicated security personnel?"]

{"sheet":"3.4.b","index":19,"n_rows":73,"n_cols":6,"rows_kept":73,"cut":false,"hidden":true,"merged":[[72,4,72,14],[15,4,15,14],[34,4,34,14],[52,5,52,14],[64,4,64,14],[68,4,68,14]]}
[]
[3,"Physical Security Management Profile"]
[]
[null,3.4,null,"Security Force Profile"]
[]
[]
[null,null,0,"3.4.1.1","Are security staff:"]
[null,null,null,null,"Facility employees"]
[null,null,null,null,"Contractor personnel"]
[null,null,null,null,"A hybrid of employees and contractor personnel"]
[]
[null,null,0,"3.4.1.2","Does the facility maintain a professional police force with law enforcement authority?"]
[]
[]
[]
[null,null,0,"3.4.1.3","Have security staffing levels been determined in accordance with applicable standards such as recommendations from the International Association of Healthcare Security and Safety?"]
[]
[]
[]
[null,null,0,"3.4.1.4","Are there policies in place that define the general orders and authorities of facility security personnel?"]
[]
[]
[]
[null,null,0,"3.4.1.5","Are use-of-force and detention protocols clearly established?"]
[]
[]
[]
[null,null,{"$f":"IF(C33=TRUE,99,COUNTIF(C30:C32,TRUE))","v":0},"3.4.1.6","With what type of weapons is the security force armed?"]
[null,null,null,null,"Check all that apply."]
[null,null,false,null,"Lethal weapons"]
[null,null,false,null,"Less-than-lethal weapons"]
[null,null,false,null,"Non-lethal weapons"]
[null,null,false,null,"Security force is not armed"]
[]
[null,null,0,"3.4.1.7","Does the security force participate in a formal weapons training and certification program appropriate for their most lethal weapons?"]
[]
[]
[]
[null,null,0,"3.4.1.8","Is the security force located on site?"]
[]
[]
[]
[null,null,0,null,"3.4.1.8.1","What is the estimated response time of the off-site security force?"]
[null,null,null,null,null,"Immediate"]
[null,null,null,null,null,"Within 10 minutes"]
[null,null,null,null,null,"Within 1 hour"]
[null,null,null,null,null,"Greater than 1 hour"]
[]
[null,null,0,"3.4.1.9","Does the security force man static posts?"]
[]
[]
[]
[null,null,0,null,"3.4.1.9.1","Is the facility, including designated sensitive areas, adequately covered by the layout of static security posts?"]
[]
[]
[]
[null,null,0,"3.4.1.10","Are roving security patrols, including vehicular patrols, used to augment static posts?"]
[]
[]
[]
[null,null,0,null,"3.4.1.10.1","If so, are sensitive areas covered by roving patrols, including vehicular patrols?"]
[]
[]
[]
[null,null,0,"3.4.1.11","Is there a defined response protocol for the security force including notification, alert, and response time components?"]
[]
[]
[]
[null,null,0,"3.4.1.12","Are there protocols in place to provide for a surge in security staff in response to an emergent threat or security incident?"]
[]
[]
[]
[null,null,0,"3.4.1.13","Are policies in place detailing how security personnel will interface with local law enforcement and other external agencies in support of the response to an emergency situation?"]

{"sheet":"3.5.a","index":20,"n_rows":60,"n_cols":5,"rows_kept":60,"cut":false,"hidden":true,"merged":[[23,3,23,14],[31,3,31,14],[35,3,35,14],[39,3,39,14],[43,3,43,14]]}
[]
[3,"Physical Security Management Profile"]
[]
[null,3.5,null,"Physical Access Control"]
[]
[]
[null,"3.5.1",0,"Does the facility maintain open access to the public?"]
[null,null,null,"Fully open to the public"]
[null,null,null,"Partially open to the public"]
[null,null,null,"Not open to the public"]
[]
[null,"3.5.2",0,"Is the facility connected to a mass transit station or other key transportation node?"]
[]
[]
[]
[null,null,0,"3.5.2.1","Is the facility access from the station:"]
[null,null,null,null,"Secured"]
[null,null,null,null,"Open to the public"]
[]
[null,"3.5.3",0,"Is there a written facility access control policy in place?"]
[]
[]
[]
[null,"3.5.4",0,"Does the access control policy address an end-of-the-day security check to ensure that the public doesn't have access to the secured areas of the facility (i.e. ensure doors are locked, a floor sweep to ensure no one is hiding in the facility, etc.)?"]
[]
[]
[]
[null,"3.5.5",0,"Is appropriate signage posted at the entrances to restricted areas?"]
[]
[]
[]
[null,"3.5.6",0,"Is access to medical treatment areas and other sensitive areas, including all doors, interior elevators, and stairwells, controlled and restricted to authorized personnel only?  "]
[]
[]
[]
[null,"3.5.7",0,"Are facility doors, locks and locking hardware, configuration, and supporting protocols routinely inspected/reviewed (facility entry points, sensitive/critical areas, hazmat storage areas, building access, emergency egress, utility areas, etc.)?"]
[]
[]
[]
[null,"3.5.8",0,"Are all facility entrances that are not open to the public (including loading dock areas) equipped with an electronic system that would alert staff to unauthorized entry/exit, or if a door has been propped open?"]
[]
[]
[]
[null,"3.5.9",0,"Are all facility entrances that are normally open to the public but closed after hours equipped with an electronic system that would alert staff to unauthorized entry/exit, or if a door has been propped open?"]
[]
[]
[]
[null,"3.5.10",0,"Are entrances that cannot be secured during facility operating hours monitored by security personnel or surveillance cameras?"]
[]
[]
[]
[null,"3.5.11",0,"Does the access control policy include a provision for recording and investigating unauthorized entry attempts?"]
[]
[]
[]
[null,"3.5.12",0,"Is there a process established to quickly shut down/lock down all or part of the facility if so required?"]
[]
[]
[]
[null,"3.5.13",0,"Are access control systems backed up immediately in the event of a loss of primary power?"]

{"sheet":"3.5.b","index":21,"n_rows":58,"n_cols":5,"rows_kept":58,"cut":false,"hidden":true,"merged":[[22,3,22,14]]}
[]
[3,"Physical Security Management Profile"]
[]
[null,3.5,null,"Physical Access Control"]
[]
[]
[null,"3.5.14",0,"Does the facility have ground floor windows (less than 18 feet from the ground)?"]
[]
[]
[]
[null,null,0,"3.5.14.1","Are there protective measures in place for the ground floor windows?"]
[]
[]
[]
[null,"3.5.15",0,"Does the facility have an air handling system with an external air intake less than or equal to 10 feet from the ground?"]
[]
[]
[]
[null,null,0,"3.5.15.1","Is the air intake protected?"]
[]
[]
[]
[null,"3.5.16",0,"Does the facility utilize perimeter and/or sensitive area fencing (including fencing around critical equipment such as generators and propane tanks), and is it routinely inspected?"]
[]
[]
[]
[null,"3.5.17",0,"Does the facility use securable pedestrian gates?"]
[]
[]
[]
[null,"3.5.18",0,"Does the facility use securable vehicle gates?"]
[]
[]
[]
[null,"3.5.19",0,"Can any vehicle be placed (legally or illegally) within 400 feet of the facility?"]
[]
[]
[]
[null,"3.5.20",0,"Does the facility have one or more avenues of high speed approach?"]
[]
[]
[]
[null,"3.5.21",0,"Does the facility use barriers to mitigate the risk associated with a high speed avenue of approach?"]
[]
[]
[]
[null,"3.5.22",0,"Does the facility use barriers to enforce potential explosive blast standoff distances?"]
[]
[]
[]
[null,"3.5.23",{"$f":"IF(C58=TRUE,99,COUNTIF(C53:C57,TRUE))","v":0},"Are there protocols in place for the following:"]
[null,null,null,"Check all that apply."]
[null,null,false,"Vehicle access?"]
[null,null,false,"Parking, including overnight parking?"]
[null,null,false,"Vehicle registration?"]
[null,null,false,"Emergency vehicles?"]
[null,null,false,"Vehicle inspection and searches?"]
[null,null,false,"None of the above."]

{"sheet":"3.6.a","index":22,"n_rows":23,"n_cols":4,"rows_kept":23,"cut":false,"hidden":true,"merged":[[10,3,10,14],[6,3,6,14]]}
[]
[3,"Physical Security Management Profile"]
[]
[null,3.6,null,"Lighting, Surveillance, and Intrusion Detection (1 of 3)"]
[]
[]
[null,"3.6.1",0,"Is the illumination of facility approaches, fences, gates, and parking areas similar and uniform in type with overlapping light pattern coverage in most areas? "]
[]
[]
[]
[null,"3.6.2",0,"Is the illumination of building entrance and delivery areas similar and uniform in type with overlapping light pattern coverage in most areas?"]
[]
[]
[]
[null,"3.6.3",0,"Are illumination systems controlled by software applications?"]
[]
[]
[]
[null,"3.6.4",0,"Are lighting systems backed up immediately in the event of a loss of primary power?"]
[]
[]
[]
[null,"3.6.5",0,"Does the facility have a policy regarding the timely inspection, repair, and or replacement of broken lighting components?"]

{"sheet":"3.6.b","index":23,"n_rows":47,"n_cols":4,"rows_kept":47,"cut":false,"hidden":true,"merged":[]}
[]
[3,"Physical Security Management Profile"]
[]
[null,3.6,null,"Lighting, Surveillance, and Intrusion Detection (2 of 3)"]
[]
[]
[null,"3.6.6",0,"To what extent does the facility utilize exterior video surveillance?"]
[null,null,null,"Exterior video surveillance is not used"]
[null,null,null,"1-10% of facility exterior is under video surveillance"]
[null,null,null,"10-25% of facility exterior is under video surveillance"]
[null,null,null,"25-50% of facility exterior is under video surveillance"]
[null,null,null,"50-75% of facility exterior is under video surveillance"]
[null,null,null,"75-100% of facility exterior is under video surveillance"]
[]
[null,"3.6.7",0,"To what extent does the facility utilize interior video surveillance?"]
[null,null,null,"Interior video surveillance is not used"]
[null,null,null,"1-10% of facility interior is under video surveillance"]
[null,null,null,"10-25% of facility interior is under video surveillance"]
[null,null,null,"25-50% of facility interior is under video surveillance"]
[null,null,null,"50-75% of facility interior is under video surveillance"]
[null,null,null,"75-100% of facility interior is under video surveillance"]
[]
[null,"3.6.8",0,"Are sensitive areas of the facility monitored using surveillance cameras?"]
[]
[]
[]
[null,"3.6.9",0,"Does a trained security staff continuously monitor the video surveillance?"]
[]
[]
[]
[null,"3.6.10",0,"Are electronic surveillance systems backed up immediately in the event of a loss of primary power?"]
[]
[]
[]
[null,"3.6.11",0,"Is video surveillance footage recorded, and how long is it stored for?"]
[null,null,null,"Video surveillance is not recorded"]
[null,null,null,"Video surveillance recordings are stored for 24 hours"]
[null,null,null,"Video surveillance recordings are stored for up to a week"]
[null,null,null,"Video surveillance recordings are stored for up to a month"]
[null,null,null,"Video surveillance recordings are stored for up to 180 days"]
[null,null,null,"Video surveillance recordings are stored for greater than 180 days"]
[]
[null,"3.6.12",0,"Are body cameras used to augment facility video surveillance?"]
[]
[]
[]
[null,"3.6.13",0,"Does the facility have a policy regarding the timely inspection, repair, and or replacement of broken surveillance components?"]

{"sheet":"3.6.c","index":24,"n_rows":19,"n_cols":5,"rows_kept":19,"cut":false,"hidden":true,"merged":[]}
[]
[3,"Physical Security Management Profile"]
[]
[null,3.6,null,"Lighting, Surveillance, and Intrusion Detection (3 of 3)"]
[]
[]
[null,"3.6.14",0,"Does the facility utilize an interior intrusion detection method or application? "]
[]
[]
[]
[null,null,0,"3.6.14.1","Are the intrusion detection systems controlled by software applications?"]
[]
[]
[]
[null,null,0,"3.6.14.2","Are the intrusion detection systems continuously monitored?"]
[]
[]
[]
[null,null,0,"3.6.14.3","Are intrusion detection and alarm systems backed up immediately in the event of a loss of primary power?"]

{"sheet":"3.7","index":25,"n_rows":53,"n_cols":5,"rows_kept":53,"cut":false,"hidden":true,"merged":[[10,3,10,14],[52,3,52,14],[40,4,40,14],[36,4,36,14],[20,4,20,14],[17,3,17,14]]}
[]
[3,"Physical Security Management Profile"]
[]
[null,3.7,null,"Badging and Internal Security"]
[]
[]
[null,"3.7.1",0,"Does the facility have a policy and supporting procedures in place that cover visitor sign-in and monitoring?"]
[]
[]
[]
[null,"3.7.2",{"$f":"IF(C19=TRUE,99,COUNTIF(C13:C18,TRUE))","v":0},"Does the facility have an identification card/badging policy that covers the issuance and re-issuance of proper means of identification for:"]
[null,null,null,"Check all that apply."]
[null,null,false,"Employees"]
[null,null,false,"Contractors"]
[null,null,false,"Volunteers"]
[null,null,false,"Vendors"]
[null,null,false,"Visitors"]
[null,null,false,"Privileged medical staff that have access to multiple facilities (e.g., physicians that have privileges at hospitals but aren't hospital employees)"]
[null,null,false,"None of the above"]
[]
[null,null,0,"3.7.2.7","Do ID cards/badges allowing employee/contractor access to designated sensitive areas of the facility have distinguishing markings?"]
[]
[]
[]
[null,null,0,"3.7.2.8","Does the identification card/badging policy hold managers accountable for compliance in their respective areas?"]
[]
[]
[]
[null,null,0,"3.7.2.9","Does the identification card/badging policy contain provisions for handling the theft or loss of ID cards/badges?"]
[]
[]
[]
[null,null,0,"3.7.2.10","Does the identification card/badging policy address the inventorying of ID cards and badges?"]
[]
[]
[]
[null,null,0,"3.7.2.11","Does the identification card/badging policy contain provisions for collecting ID cards/badges from departing or terminated employees/contractors?"]
[]
[]
[]
[null,null,0,"3.7.2.12","Does the identification card/badging policy contain guidance regarding the use of double-sided badging and the prohibition of stickers or obstructive attachments?"]
[]
[]
[]
[null,"3.7.3",0,"Are visitors screened and issued appropriate means of identification upon entrance to the facility?"]
[]
[]
[]
[null,"3.7.4",0,"Are sensitive areas of the facility and facility visitor reception areas equipped with panic alarms?"]
[]
[]
[]
[null,"3.7.5",0,"Does the facility have a key issuance, control, inventory, and accountability policy in place, including protocols for lost/stolen keys and for collecting keys from departing or terminated staff?"]

{"sheet":"4.1","index":26,"n_rows":50,"n_cols":4,"rows_kept":50,"cut":false,"hidden":true,"merged":[[37,3,37,14],[41,3,41,14],[45,3,45,14],[49,3,49,14],[6,3,6,14],[10,3,10,14],[16,3,16,14],[25,3,25,14],[29,3,29,14],[33,3,33,14]]}
[]
[4,"Critical Dependencies"]
[]
[null,4.0999999999999996,null,"General Dependencies"]
[]
[]
[null,"4.1.1",0,"Does the facility identify single points of failure and protect areas in which systems, such as HVAC, and utilities, including water, steam, electrical power, communications, compressed gases, and/or chilled water, are produced or distributed in order to minimize the opportunity for disruption of those services?"]
[]
[]
[]
[null,"4.1.2",0,"Has the facility identified and documented its critical dependencies across the spectrum of the critical services it provides (including critical satellite operations)?"]
[]
[]
[]
[null,"4.1.3",{"$f":"IF(C20=TRUE,99,COUNTIF(C17:C19,TRUE))","v":0},"Does the facility identify alternative means of providing the following at both the main facility and satellite operations:"]
[null,null,null,"Check all that apply."]
[null,null,false,"Supporting systems that the facility defines as essential (e.g., vertical and horizontal transport, heating and cooling systems, and steam for sterilization) "]
[null,null,false,"Critical supplies (e.g., critical chemicals, medical gas, fuel, potable water) "]
[null,null,false,"Critical equipment (e.g., generators, HVAC spare parts)"]
[null,null,false,"None of the above"]
[]
[null,"4.1.4",0,"Does the facility identify how it will monitor the quantities of resources and assets expended during an emergency?"]
[]
[]
[]
[null,"4.1.5",0,"Has the facility determined how long it can sustain critical operations given a disruption or loss of critical external commodities or services, and is this timeframe accounted for in facility emergency operations plans?"]
[]
[]
[]
[null,"4.1.6",0,"Does the facility identify how it will obtain and replenish medications and other critical medical supplies that will be required throughout the response and recovery phases of an emergency, including access to and distribution of caches that may be stockpiled by the facility; its affiliates; and/or local, state, or federal sources?"]
[]
[]
[]
[null,"4.1.7",0,"Does the facility identify how it will obtain and replenish nonmedical supplies that will be required throughout the response and recovery phases of an emergency?"]
[]
[]
[]
[null,"4.1.8",0,"Does the facility account for the loss of critical systems such as HVAC and utilities and include separate means for redundancy in the delivery of purchased utilities, including gas, water, steam, electrical power, telecommunications, and IT services? "]
[]
[]
[]
[null,"4.1.9",0,"Are MOAs in place with publicly owned utilities to help ensure the availability of critical services during an emergency or disaster?"]
[]
[]
[]
[null,"4.1.10",0,"Have such MOAs been deconflicted to account for a surge in demand for similar services on the part of other customers impacted by the same emergency/disaster?"]
[]
[]
[]
[null,"4.1.11",0,"Has the facility tested/validated contractual mechanisms, MOAs, supply chain continuity arrangements, and identified critical dependency mitigation measures through exercises or other such activities?"]

{"sheet":"4.2","index":27,"n_rows":77,"n_cols":6,"rows_kept":77,"cut":false,"hidden":true,"merged":[[37,3,37,14],[33,3,33,14],[10,3,10,14],[6,3,6,14],[71,3,71,14],[64,3,64,14],[57,3,57,14],[53,3,53,14],[49,3,49,14],[41,4,41,14]]}
[]
[4,"Critical Dependencies"]
[]
[null,4.2,null,"Information Technology (IT)"]
[]
[]
[null,"4.2.1",0,"Are the facility’s core functions (including critical satellite operations) dependent on data processing systems (mainframes, cloud providers, server farms, etc.)?"]
[]
[]
[]
[null,"4.2.2",0,"Are managers, employees, and contractor personnel aware of critical IT-related dependencies linked to essential functions, as well as corresponding back-up systems and protocols?"]
[]
[]
[]
[null,null,0,"4.2.2.1","If so, have these dependencies been documented?"]
[]
[]
[]
[null,"4.2.3",0,"Where are the primary data processing devices/systems (including those supporting critical satellite operations) located?"]
[null,null,null,"On-site"]
[null,null,null,"Off-site"]
[]
[null,"4.2.4",0,"Is there an encrypted back-up capability in place in the event of a failure or disruption of primary devices/systems?"]
[]
[]
[]
[null,"4.2.5",{"$f":"IF(C32=TRUE,99,COUNTIF(C29:C31,TRUE))","v":0},"Are back-up capabilities:"]
[null,null,null,"Check all that apply."]
[null,null,false,"Tape based"]
[null,null,false,"Cloud based"]
[null,null,false,"Physical server based"]
[null,null,false,"None of the above"]
[]
[null,"4.2.6",0,"Has the facility determined a recovery time objective for their primary software capabilities (internal, e.g. billing, as well as external)?"]
[]
[]
[]
[null,"4.2.7",0,"Are data processing and cybersecurity functions (including those supporting critical satellite operations) managed, in whole or in part, by a third-party service provider, vendor, or contractor? "]
[]
[]
[]
[null,null,0,"4.2.7.1","Are third-party service providers bound by contract to maintain an appropriate back-up capability in the event of a failure or disruption of primary systems?"]
[]
[]
[]
[null,null,0,null,"4.2.7.1.1","If so, has this capability been tested, including relevant “hand-off” protocols?"]
[]
[]
[]
[null,"4.2.8",0,"Does the facility participate in a provider priority plan for restoration of critical IT services, including those associated with critical satellite operations?"]
[]
[]
[]
[null,"4.2.9",0,"Does the organization have alternative or backup storage capabilities that can be used in case of loss of the primary data storage?"]
[]
[]
[]
[null,"4.2.10",0,"If internal data service, such as company-owned assets including mobile devices with access to the network, is lost (without considering any backup or alternative mode), how soon would the facility be severely impacted (i.e., greater than 50% reduction of priority services)?"]
[null,null,null,"Immediately"]
[null,null,null,"Within 24 hours"]
[null,null,null,"Within 72 hours"]
[null,null,null,"Within one week"]
[null,null,null,"More than one week"]
[]
[null,"4.2.11",0,"If external data service is lost (without considering any backup or alternative mode), how soon would the facility and/or critical satellite operations be severely impacted (i.e., greater than 50% reduction of priority services)?"]
[null,null,null,"Immediately"]
[null,null,null,"Within 24 hours"]
[null,null,null,"Within 72 hours"]
[null,null,null,"Within one week"]
[null,null,null,"More than one week"]
[]
[null,"4.2.12",0,"Once external data service is lost (without considering any backup or alternative mode), how soon would normal functionality of the facility and/or critical satellite operations be restored?"]
[null,null,null,"Immediately"]
[null,null,null,"Within 24 hours"]
[null,null,null,"Within 72 hours"]
[null,null,null,"Within one week"]
[null,null,null,"More than one week"]

{"sheet":"4.3","index":28,"n_rows":70,"n_cols":7,"rows_kept":70,"cut":false,"hidden":true,"merged":[[64,3,64,14],[57,3,57,14],[14,3,14,14],[38,6,39,13]]}
[]
[4,"Critical Dependencies"]
[]
[null,4.3,null,"Electricity"]
[]
[]
[null,"4.3.1",0,"Is the facility dependent upon an external source of electrical power?"]
[]
[]
[]
[null,"4.3.2",0,"Does the facility maintain more than one connection for electric service?"]
[]
[]
[]
[null,"4.3.3",0,"Does the facility possess and maintain back-up batteries and/or backup generator(s) capable of immediately powering and running mission critical services for 96 hours?"]
[]
[]
[]
[null,"4.3.4",0,"Are weekly/monthly backup generator testing and inspections conducted and documented?"]
[]
[]
[]
[null,"4.3.5",0,"Are there parts on hand for switch gear equipment that may fail?"]
[]
[]
[]
[null,"4.3.6",0,"Are back-up sources of electric power positioned in “survivable” locations?"]
[]
[]
[]
[null,"4.3.7",0,"Does the facility maintain “quick connects” to enable the rapid installation of external generators?"]
[]
[]
[]
[null,"4.3.8",0,"Does the facility have any specialty fuel needs?"]
[]
[]
[null,null,null,null,null,null,"Specify specialty fuel needs below"]
[]
[]
[]
[null,"4.3.9",0,"Does the facility maintain a fuel supply on hand to power emergency generators for at least 96 hours?"]
[]
[]
[]
[null,"4.3.10",0,"Are contracts in place to bring in additional fuel for long-term outages? "]
[]
[]
[]
[null,null,0,"4.3.10.1","If not, is there an additional contingency plan to ensure fuel availability for outages lasting more than 96 hours?"]
[]
[]
[]
[null,"4.3.11",0,"Does the facility participate in a power provider priority plan for restoration?"]
[]
[]
[]
[null,"4.3.12",0,"If external electric service is lost (without considering any backup or alternative mode), how soon would the facility and/or critical satellite operations be severely impacted (i.e., greater than 50% reduction of priority services)?"]
[null,null,null,"Immediately"]
[null,null,null,"Within 24 hours"]
[null,null,null,"Within 72 hours"]
[null,null,null,"Within one week"]
[null,null,null,"More than one week"]
[]
[null,"4.3.13",0,"Once external electric service is lost (without considering any backup or alternative mode), how soon would normal functionality of the facility and/or critical satellite operations be restored?"]
[null,null,null,"Immediately"]
[null,null,null,"Within 24 hours"]
[null,null,null,"Within 72 hours"]
[null,null,null,"Within one week"]
[null,null,null,"More than one week"]

{"sheet":"4.4","index":29,"n_rows":47,"n_cols":4,"rows_kept":47,"cut":false,"hidden":true,"merged":[[41,3,41,14],[34,3,34,14],[26,3,26,14]]}
[]
[4,"Critical Dependencies"]
[]
[null,4.4000000000000004,null,"Natural Gas"]
[]
[]
[null,"4.4.1",0,"Is the facility’s core function dependent on access to natural gas?"]
[]
[]
[]
[null,"4.4.2",0,"Does the facility have a combined heat and power system?"]
[]
[]
[]
[null,"4.4.3",0,"Is the primary source of natural gas an external provider?"]
[]
[]
[]
[null,"4.4.4",0,"Is there more than one natural gas connection or service line to the facility?"]
[]
[]
[]
[null,"4.4.5",0,"Is there a secondary source of natural gas? "]
[]
[]
[]
[null,"4.4.6",0,"Can alternate forms of energy, such as biogas, be substituted for natural gas in the context of a long duration supply disruption?"]
[]
[]
[]
[null,"4.4.7",0,"Does the facility participate in a natural gas provider priority plan for restoration?"]
[]
[]
[]
[null,"4.4.8",0,"If external natural gas service is lost (without considering any backup or alternative mode), how soon would the facility and/or critical satellite operations be severely impacted (i.e., greater than 50% reduction of priority services)?"]
[null,null,null,"Immediately"]
[null,null,null,"Within 24 hours"]
[null,null,null,"Within 72 hours"]
[null,null,null,"Within one week"]
[null,null,null,"More than one week"]
[]
[null,"4.4.9",0,"Once external natural gas service is lost (without considering any backup or alternative mode), how soon would normal functionality of the facility and/or critical satellite operations be restored?"]
[null,null,null,"Immediately"]
[null,null,null,"Within 24 hours"]
[null,null,null,"Within 72 hours"]
[null,null,null,"Within one week"]
[null,null,null,"More than one week"]

{"sheet":"4.5","index":30,"n_rows":45,"n_cols":4,"rows_kept":45,"cut":false,"hidden":true,"merged":[[39,3,39,14],[32,3,32,14],[20,3,20,14]]}
[]
[4,"Critical Dependencies"]
[]
[null,4.5,null,"Water"]
[]
[]
[null,"4.5.1",0,"Does the facility rely on an external source for primary supply of water?"]
[]
[]
[]
[null,"4.5.2",{"$f":"IF(C15=TRUE,99,COUNTIF(C13:C14,TRUE))","v":0},"Is there a secondary source of water?"]
[null,null,null,"Check all that apply."]
[null,null,false,"On-site"]
[null,null,false,"Off-site"]
[null,null,false,"No secondary source of water"]
[]
[null,"4.5.3",0,"Does the facility have a mutual aid agreement or contract services for potable and service use water?"]
[]
[]
[]
[null,"4.5.4",0,"Does the facility maintain onsite water storage capacity capable of sustaining human needs, designated critical operations, and critical systems such as HVAC? "]
[]
[]
[]
[null,"4.5.5",0,"Does the facility have a backup in case of loss of water pressure, especially if it is a multiple story facility?"]
[]
[]
[]
[null,"4.5.6",0,"Does the facility participate in a water provider priority plan for restoration?"]
[]
[]
[]
[null,"4.5.7",0,"If external water service is lost (without considering any backup or alternative mode), how soon would the facility and/or critical satellite operations be severely impacted (i.e., greater than 50% reduction of priority services)?"]
[null,null,null,"Immediately"]
[null,null,null,"Within 24 hours"]
[null,null,null,"Within 72 hours"]
[null,null,null,"Within one week"]
[null,null,null,"More than one week"]
[]
[null,"4.5.8",0,"Once external water service is lost (without considering any backup or alternative mode), how soon would normal functionality of the facility and/or critical satellite operations be restored?"]
[null,null,null,"Immediately"]
[null,null,null,"Within 24 hours"]
[null,null,null,"Within 72 hours"]
[null,null,null,"Within one week"]
[null,null,null,"More than one week"]

{"sheet":"4.6","index":31,"n_rows":43,"n_cols":4,"rows_kept":43,"cut":false,"hidden":true,"merged":[[37,3,37,14],[30,3,30,14]]}
[]
[4,"Critical Dependencies"]
[]
[null,4.5999999999999996,null,"Wastewater and Waste Disposal"]
[]
[]
[null,"4.6.1",0,"Is the facility’s core function dependent on continuous access to wastewater discharge and waste disposal services? "]
[]
[]
[]
[null,"4.6.2",0,"Is there an on-site waste incineration capability?"]
[]
[]
[]
[null,"4.6.3",0,"Is there on-site sterilization (e.g., autoclave) capability?"]
[]
[]
[]
[null,"4.6.4",0,"Does the facility have the ability to bring in portable wastewater and waste disposal services (including hazmat disposal)?"]
[]
[]
[]
[null,"4.6.5",0,"Is there a secondary source of wastewater discharge and waste disposal services (including hazmat disposal)? "]
[]
[]
[]
[null,"4.6.6",0,"Does the facility participate in wastewater discharge service provider priority plan for restoration?"]
[]
[]
[]
[null,"4.6.7",0,"If external wastewater service and/or waste disposal service (including hazmat disposal) is lost (without considering any backup or alternative mode), how soon would the facility and/or critical satellite operations be severely impacted (i.e., greater than 50% reduction of priority services)?"]
[null,null,null,"Immediately"]
[null,null,null,"Within 24 hours"]
[null,null,null,"Within 72 hours"]
[null,null,null,"Within one week"]
[null,null,null,"More than one week"]
[]
[null,"4.6.8",0,"Once external wastewater service and/or waste disposal service (including hazmat disposal) is lost (without considering any backup or alternative mode), how soon would normal functionality of the facility and/or critical satellite operations be restored?"]
[null,null,null,"Immediately"]
[null,null,null,"Within 24 hours"]
[null,null,null,"Within 72 hours"]
[null,null,null,"Within one week"]
[null,null,null,"More than one week"]

{"sheet":"4.7","index":32,"n_rows":39,"n_cols":4,"rows_kept":39,"cut":false,"hidden":true,"merged":[[33,3,33,14],[26,3,26,14]]}
[]
[4,"Critical Dependencies"]
[]
[null,4.7,null,"Communications"]
[]
[]
[null,"4.7.1",0,"Are the facility’s core functions dependent on continuous access to communications infrastructure?"]
[null,null,null,"For example: wired phone, wired data, cell phone, etc."]
[]
[]
[]
[null,"4.7.2",0,"If the primary mode of communication service is lost, is there a backup mode of communication?"]
[]
[]
[]
[null,"4.7.3",0,"Does the facility participate in a communications provider priority plan for restoration?"]
[]
[]
[]
[null,"4.7.4",{"$f":"IF(C25=TRUE,99,COUNTIF(C22:C24,TRUE))","v":0},"Does the facility have an emergency backup for phone service including the following?"]
[null,null,null,"Check all that apply."]
[null,null,false,"Wireless Provider Service (WPS)"]
[null,null,false,"Government Emergency Telecommunication Services (GETS)"]
[null,null,false,"Telecommunications Service Priority (TSP)"]
[null,null,false,"None of the above"]
[]
[null,"4.7.5",0,"If external communications service is lost (without considering any backup or alternative mode), how soon would the facility and/or critical satellite operations be severely impacted (i.e., greater than 50% reduction of priority services)?"]
[null,null,null,"Immediately"]
[null,null,null,"Within 24 hours"]
[null,null,null,"Within 72 hours"]
[null,null,null,"Within one week"]
[null,null,null,"More than one week"]
[]
[null,"4.7.6",0,"Once external communications service is lost (without considering any backup or alternative mode), how soon would normal functionality of the facility and/or critical satellite operations be restored?"]
[null,null,null,"Immediately"]
[null,null,null,"Within 24 hours"]
[null,null,null,"Within 72 hours"]
[null,null,null,"Within one week"]
[null,null,null,"More than one week"]

{"sheet":"4.8","index":33,"n_rows":35,"n_cols":7,"rows_kept":35,"cut":false,"hidden":true,"merged":[[29,3,29,14],[22,3,22,14],[18,3,18,14],[6,3,6,14],[11,6,12,13]]}
[]
[4,"Critical Dependencies"]
[]
[null,4.8,null,"Transportation"]
[]
[]
[null,"4.8.1",0,"Are the facility’s core functions (including continuity in critical supply chains and the ability of essential staff to report for duty during local or regional emergencies) dependent on access to specific transportation modes or routes with a single point of failure?"]
[null,null,null,"For example, specific roadways, bridges, tunnels, or mass transit lines"]
[]
[]
[null,null,null,null,null,null,"If Yes, specify key transportation dependencies below"]
[]
[]
[]
[null,"4.8.2",0,"Does the facility identify alternative means of essential transportation services for staff and patients?"]
[]
[]
[]
[null,"4.8.3",0,"Does the facility have an established plan for credentialing and authorized movement of critical staff in emergency situations where access into the impacted are may be limited?"]
[]
[]
[]
[null,"4.8.4",0,"If key external transportation service is lost (without considering any backup or alternative mode), how soon would the facility and/or critical satellite operations be severely impacted (i.e., greater than 50% reduction of priority services)?"]
[null,null,null,"Immediately"]
[null,null,null,"Within 24 hours"]
[null,null,null,"Within 72 hours"]
[null,null,null,"Within one week"]
[null,null,null,"More than one week"]
[]
[null,"4.8.5",0,"Once key external transportation service is lost (without considering any backup or alternative mode), how soon would normal functionality of the facility and/or critical satellite operations be restored?"]
[null,null,null,"Immediately"]
[null,null,null,"Within 24 hours"]
[null,null,null,"Within 72 hours"]
[null,null,null,"Within one week"]
[null,null,null,"More than one week"]

{"sheet":"4.9","index":34,"n_rows":83,"n_cols":9,"rows_kept":83,"cut":false,"hidden":true,"merged":[[42,3,42,14],[74,3,74,14],[70,3,70,14],[62,3,62,14],[50,4,50,14],[46,4,46,14],[12,8,12,13],[35,3,35,14],[28,3,28,14],[21,3,21,14],[14,3,14,14]]}
[]
[4,"Critical Dependencies"]
[]
[null,4.9000000000000004,null,"Critical Products"]
[]
[]
[null,"4.9.1",{"$f":"SUM(C9:C10)","v":0},"Are the facility’s core functions dependent on access to the following critical products?"]
[]
[null,null,0,"4.9.1.1","Chemicals"]
[null,null,0,"4.9.1.2","Other critical supplies/equipment"]
[]
[null,null,null,null,null,null,null,null,"Specify other critical supplies/equipment below"]
[]
[]
[null,"4.9.2",0,"If the critical chemical supply source(s) is lost (without considering any backup or alternative mode), how soon would the facility and/or critical satellite operations be severely impacted (i.e., greater than 50% reduction of priority services)?"]
[null,null,null,"Immediately"]
[null,null,null,"Within 24 hours"]
[null,null,null,"Within 72 hours"]
[null,null,null,"Within one week"]
[null,null,null,"More than one week"]
[]
[null,"4.9.3",0,"Once the critical chemical supply source(s) is lost (without considering any backup or alternative mode), how soon would normal functionality of the facility and/or critical satellite operations be restored?"]
[null,null,null,"Immediately"]
[null,null,null,"Within 24 hours"]
[null,null,null,"Within 72 hours"]
[null,null,null,"Within one week"]
[null,null,null,"More than one week"]
[]
[null,"4.9.4",0,"If access to critical supplies/equipment is lost (without considering any backup or alternative mode), how soon would the facility and/or critical satellite operations be severely impacted (i.e., greater than 50% reduction of priority services)?"]
[null,null,null,"Immediately"]
[null,null,null,"Within 24 hours"]
[null,null,null,"Within 72 hours"]
[null,null,null,"Within one week"]
[null,null,null,"More than one week"]
[]
[null,"4.9.5",0,"Once access to critical supplies/equipment is lost (without considering any backup or alternative mode), how soon would normal functionality of the facility and/or critical satellite operations be restored?"]
[null,null,null,"Immediately"]
[null,null,null,"Within 24 hours"]
[null,null,null,"Within 72 hours"]
[null,null,null,"Within one week"]
[null,null,null,"More than one week"]
[]
[null,"4.9.6",0,"In the event of a disruption affecting critical product suppliers, are back-up arrangements and/or contracts in place with alternate suppliers? "]
[]
[]
[]
[null,null,0,"4.9.6.1","Have such arrangements been deconflicted to account for a surge in demand for similar commodities and services on the part of other customers impacted by the same emergency/disaster?"]
[]
[]
[]
[null,null,0,"4.9.6.2","Have these been tested to ensure their validity in emergency situations in which multiple affected facilities are relying on the same vendors/contractors for similar services?"]
[]
[]
[]
[null,"4.9.7",0,"Are critical products for emergency operations determined on the basis of risk assessments and analyses?"]
[]
[]
[]
[null,"4.9.8",0,"Are there any critical supplies that the facility obtains from a single supplier/distributor?"]
[]
[]
[]
[null,"4.9.9",0,"Are current contracts designed to reflect emergency needs (e.g. type of commodity, quantity of commodity, and timeliness of delivery) based on risk assessments and analysis as well as exercise lessons learned?"]
[]
[]
[]
[null,"4.9.10",0,"Are critical products readily available in sufficient quantities?"]
[]
[]
[]
[null,"4.9.11",0,"Are critical products periodically tested, and are expired or inappropriate items disposed of in accordance with established guidelines?"]
[]
[]
[]
[null,"4.9.12",0,"Are maintenance of the inventory and the rotation and safe stockpiling of critical products executed in accordance with established guidelines?"]
[]
[]
[]
[null,"4.9.13",0,"Is there a system in place for the distribution of critical products in the event of an HPH Sector emergency?"]
[]
[]
[]
[null,"4.9.14",0,"Do procedures exist for the exceptional procurement of critical products that are not on the list of basic equipment?"]

{"sheet":"5.1","index":35,"n_rows":122,"n_cols":7,"rows_kept":122,"cut":false,"hidden":true,"merged":[[93,3,93,14],[117,3,117,14],[20,3,20,14],[46,3,46,14],[50,3,50,14],[54,3,54,14],[65,3,65,14],[73,3,73,14],[62,6,63,13],[90,6,91,13]]}
[]
[5,"Cybersecurity Management Profile"]
[]
[null,5.0999999999999996,null,"Identify"]
[]
[]
["5.1.1","Asset Management"]
[]
[null,"5.1.1.1",0,"How frequently are physical IT devices and systems and back-ups within the organization inventoried?"]
[null,null,null,"At least semiannually (twice per year)"]
[null,null,null,"Annually (once per year)"]
[null,null,null,"Biannually (every two years)"]
[null,null,null,"Inventory of physical IT devices, systems, and backups is not conducted"]
[]
[null,"5.1.1.2",0,"How frequently are IT software platforms and applications and back-ups within the organization inventoried?"]
[null,null,null,"At least semiannually (twice per year)"]
[null,null,null,"Annually (once per year)"]
[null,null,null,"Biannually (every two years)"]
[null,null,null,"Inventory of IT software platforms, applications, and backups is not conducted"]
[]
[null,"5.1.1.3",0,"Are IT resources (e.g., hardware, devices, data, and software) prioritized based on their classification, criticality, and business value?"]
[]
[]
[]
[null,"5.1.1.4",0,"Has a compliance audit been conducted of all identified primary and back-up critical IT assets?"]
[]
[]
[]
[null,"5.1.1.5",0,"Are organizational communication and data flows linked to identified primary and back-up Critical IT assets?"]
[]
[]
[]
[null,"5.1.1.6",0,"Are external IT services catalogued and audited for security purposes appropriately?"]
[]
[]
[]
["5.1.2","Governance"]
[]
[null,"5.1.2.1",0,"Is there a designated manager/department in charge of information security management?"]
[]
[]
[]
[null,"5.1.2.2",0,"Is organizational information security policy established?"]
[]
[]
[]
[null,"5.1.2.3",0,"Is there a documented cybersecurity plan and IT security architecture in place, including appropriate physical security protocols, that includes each of the identified primary and back-up critical cybersecurity assets?"]
[]
[]
[]
[null,"5.1.2.4",0,"Are information security roles and responsibilities defined in policy/plans for management, employees, and third-party stakeholders (e.g., suppliers, customers, partners)?"]
[]
[]
[]
[null,"5.1.2.5",0,"Are appropriate procurement and contracting measures employed to specify and enforce cybersecurity requirements for third party service providers, vendors, and contractors?"]
[]
[]
[]
[null,"5.1.2.6",0,"Are recognized cyber-security standards of practice adhered to?"]
[null,null,null,"E.g., NIST Cybersecurity Framework, HIPAA, ISO/IEC 27000 series, etc."]
[]
[null,null,null,null,null,null,"Specify standards followed"]
[]
[]
[]
[null,"5.1.2.7",0,"Are legal and regulatory requirements regarding cybersecurity, including privacy and civil liberties obligations, understood and managed?"]
[]
[]
[]
[null,"5.1.2.8",0,"Do corporate governance and risk management processes identify and address cybersecurity risks?"]
[]
[]
[]
[null,"5.1.2.9",0,"Are security policy violations on system networks (e.g., unauthorized reads, writes, access, etc.), both primary and back-up, recorded and audited?"]
[]
[]
[]
["5.1.3","Risk Assessment"]
[]
[null,"5.1.3.1",0,"Are cyber threats, both internal and external, identified and documented?"]
[]
[]
[]
[null,"5.1.3.2",0,"Are IT asset vulnerabilities identified and documented?"]
[]
[]
[]
[null,"5.1.3.3",0,"Is cyber threat and vulnerability information received from external information sharing forums and sources?"]
[]
[null,null,null,null,null,null,"Specify sources below"]
[]
[]
[]
[null,"5.1.3.4",0,"Are potential mission business impacts and likelihoods of occurrence related to catalogued threats and vulnerabilities identified?"]
[]
[]
[]
[null,"5.1.3.5",0,"Are cyber threats, vulnerabilities, likelihoods of occurrence, and impacts used to determine risk?"]
[]
[]
[]
[null,"5.1.3.6",{"$f":"IF(C108=TRUE,99,COUNTIF(C104:C107,TRUE))","v":0},"Does the facility conduct a periodic cyber risk assessment and security gap analysis, including:"]
[null,null,null,"Check all that apply."]
[null,null,false,"Identification and documentation of asset vulnerabilities"]
[null,null,false,"Identification and documentation of threats, both internal and external"]
[null,null,false,"Receipt of threat and vulnerability information from outside sources"]
[null,null,false,"Determination of business impacts and likelihoods"]
[null,null,false,"None of the above"]
[]
[null,"5.1.3.7",0,"Is a cyber risk assessment and security gap analysis conducted on a recurring basis?"]
[null,null,null,"At least semiannually (twice per year)"]
[null,null,null,"Annually (once per year)"]
[null,null,null,"Biannually (every two years)"]
[null,null,null,"Cyber risk assessment and security gap analysis is not conducted"]
[]
["5.1.4","Risk Management Strategy"]
[]
[null,"5.1.4.1",0,"Are cyber risk management processes established, managed, and agreed to by internal and external organizational stakeholders?"]
[]
[]
[]
[null,"5.1.4.2",0,"Is organizational cyber risk tolerance determined and clearly expressed in policy?"]

{"sheet":"5.2.a","index":36,"n_rows":85,"n_cols":5,"rows_kept":85,"cut":false,"hidden":true,"merged":[[80,3,80,14],[42,3,42,14],[16,3,16,14],[8,3,8,14]]}
[]
[5,"Cybersecurity Management Profile"]
[]
[null,5.2,null,"Protect (1 of 2)"]
[]
[]
["5.2.1","Access Control"]
[]
[null,"5.2.1.1",0,"Is a process established for identity proofing and authentication to limit access to critical primary and back-up IT systems to only authorized persons and automated systems? "]
[]
[]
[]
[null,null,0,"5.2.1.1.1","If so, has it been tested for effectiveness?"]
[]
[]
[]
[null,"5.2.1.2",0,"Is the concept of least privileges and separation of duties practiced (i.e., users are only granted access to the information, files and applications required to perform their specific duties)?"]
[]
[]
[]
[null,"5.2.1.3",0,"Is physical access to IT assets managed and protected?"]
[]
[]
[]
[null,"5.2.1.4",0,"Is remote access to critical cyber services/assets allowed?"]
[]
[]
[]
[null,"5.2.1.5",0,"Is there a protocol in place to protect remotely accessed primary and back-up systems? "]
[]
[]
[]
[null,null,0,"5.2.1.5.1","If so, has it been tested for effectiveness?"]
[]
[]
[]
[null,"5.2.1.6",0,"Is there a protocol for removing, suspending, or modifying user accounts upon change of employment status?"]
[]
[]
[]
["5.2.2","Awareness and Training"]
[]
[null,"5.2.2.1",0,"Are all IT system users trained to the appropriate level of competency on the cybersecurity plan/policy both during initial onboarding as well as on a recurring basis?"]
[]
[]
[]
[null,null,0,"5.2.2.1.1","Is such training appropriately documented and reviewed?"]
[]
[]
[]
[null,"5.2.2.2",0,"Do IT system users take part in specialized cybersecurity drill and exercise activities?"]
[null,null,null,"At least semiannually (twice per year)"]
[null,null,null,"Annually (once per year)"]
[null,null,null,"Biannually (every two years)"]
[null,null,null,"IT system users do not take part in specialized cybersecurity drills and exercise activities"]
[]
[null,"5.2.2.3",0,"Are appropriate levels of cybersecurity training provided to senior executive staff and managers? "]
[]
[]
[]
[null,null,0,"5.2.2.3.1","Is such training appropriately documented and reviewed?"]
[]
[]
[]
[null,"5.2.2.4",0,"Do senior executives/managers take part in specialized cybersecurity drill and exercise activities?"]
[]
[]
[]
[null,"5.2.2.5",0,"Are appropriate levels of cybersecurity training provided for IT/cybersecurity staff? "]
[]
[]
[]
[null,null,0,"5.2.2.5.1","Is such training appropriately documented and reviewed?"]
[]
[]
[]
[null,"5.2.2.6",0,"Do IT/cybersecurity staff members take part in specialized cybersecurity drill and exercise activities? "]
[]
[]
[]
[null,"5.2.2.7",0,"Are third-party stakeholder (e.g., suppliers, customers, partners) cybersecurity training requirements established in contracts, memoranda of understanding, etc.?"]
[]
[]
[]
[null,"5.2.2.8",0,"Do third party stakeholders take part in specialized cybersecurity drill and exercise activities? "]

{"sheet":"5.2.b","index":37,"n_rows":95,"n_cols":5,"rows_kept":95,"cut":false,"hidden":true,"merged":[[80,3,80,14],[76,3,76,14],[40,3,40,14]]}
[]
[5,"Cybersecurity Management Profile"]
[]
[null,5.2,null,"Protect (2 of 2)"]
[]
[]
["5.2.3","Data Security"]
[]
[null,"5.2.3.1",0,"Is data protection enhanced through the use of data encryption practices? "]
[]
[]
[]
[null,null,0,"5.2.3.1.1","If so, have such practices been tested for effectiveness?"]
[]
[]
[]
[null,"5.2.3.2",0,"Is data-at-rest protected? "]
[]
[]
[]
[null,null,0,"5.2.3.2.1","If so, have corresponding protocols been tested for effectiveness?"]
[]
[]
[]
[null,"5.2.3.3",0,"Is data in transit protected? "]
[]
[]
[]
[null,null,0,"5.2.3.3.1","If so, have corresponding protocols been tested for effectiveness?"]
[]
[]
[]
[null,"5.2.3.4",0,"Are appropriate measures employed to address data confidentiality and integrity for both primary and back-up systems? "]
[]
[]
[]
[null,null,0,"5.2.3.4.1","If so, have corresponding protocols been tested for effectiveness?"]
[]
[]
[]
[null,"5.2.3.5",0,"Are protocols aligned with relevant standards/regulations for the protection of personal healthcare information in place for both primary and back-up systems?"]
[]
[]
[]
[null,"5.2.3.6",0,"Are protections against data leaks implemented?"]
[]
[]
[]
["5.2.4","Protect"]
[]
[null,"5.2.4.1",0,"Are protocols in place for the protection of medical devices and related information?"]
[]
[]
[]
[null,"5.2.4.2",0,"Are backups of information conducted, maintained, and tested periodically?"]
[]
[]
[]
[null,"5.2.4.3",0,"Are policy and regulatory requirements regarding the physical operating environment for organizational IT assets met?"]
[]
[]
[]
[null,"5.2.4.4",0,"Is data destroyed according to established policy?"]
[]
[]
[]
[null,"5.2.4.5",0,"Are protection processes continuously improved?"]
[]
[]
[]
[null,"5.2.4.6",0,"Is cybersecurity included in human resources practices (e.g., personnel screening, performance appraisals, etc.)?"]
[]
[]
[]
["5.2.5","Maintenance"]
[]
[null,"5.2.5.1",0,"Are maintenance and repair of organizational IT assets performed and logged in a timely manner, with approved and controlled tools?"]
[]
[]
[]
[null,"5.2.5.2",0,"Are remote maintenance of organizational IT assets approved, logged, and performed in a manner that prevents unauthorized access?"]
[]
[]
[]
["5.2.6","Protective Technology"]
[]
[null,"5.2.6.1",0,"Are audit/log records determined, documented, implemented, and reviewed in accordance with policy?"]
[]
[]
[]
[null,"5.2.6.2",0,"Is removable media protected and its use restricted according to policy?"]
[]
[]
[]
[null,"5.2.6.3",0,"Are communications and control networks protected?"]

{"sheet":"5.3","index":38,"n_rows":83,"n_cols":4,"rows_kept":83,"cut":false,"hidden":true,"merged":[[42,3,42,14],[38,3,38,14]]}
[]
[5,"Cybersecurity Management Profile"]
[]
[null,5.3,null,"Detect"]
[]
[]
["5.3.1","Anomalies and Events"]
[]
[null,"5.3.1.1",0,"Is a baseline of network operations and expected data flows for users and systems established and managed?"]
[]
[]
[]
[null,"5.3.1.2",0,"Are detected events analyzed to understand attack targets and methods?"]
[]
[]
[]
[null,"5.3.1.4",0,"Is the impact of events determined and catalogued?"]
[]
[]
[]
[null,"5.3.1.5",0,"Are cyber incident alert thresholds established?"]
[]
[]
[]
["5.3.2","Security Continuous Monitoring"]
[]
[null,"5.3.2.1",0,"Is the network monitored to detect potential cybersecurity events?"]
[]
[]
[]
[null,"5.3.2.2",0,"Is the physical environment monitored to detect potential cybersecurity events?"]
[]
[]
[]
[null,"5.3.2.3",0,"Is personnel activity monitored to detect potential cybersecurity events?"]
[]
[]
[]
[null,"5.3.2.4",0,"Are system configuration monitoring procedures and/or tools used that measure secure configuration elements and report configuration vulnerability information for both primary and back-up systems?"]
[]
[]
[]
[null,"5.3.2.5",{"$f":"IF(C51=TRUE,99,COUNTIF(C45:C50,TRUE))","v":0},"Are cybersecurity measures employed to monitor networks related to critical primary and back-up IT systems for the following threats?"]
[null,null,null,"Check all that apply."]
[null,null,false,"Malicious code"]
[null,null,false,"Unauthorized access"]
[null,null,false,"Intrusion detection"]
[null,null,false,"Ransomware"]
[null,null,false,"Data exfiltration"]
[null,null,false,"Unauthorized mobile code"]
[null,null,false,"None of the above"]
[]
[null,"5.3.2.6",0,"Is external service provider activity monitored to detect potential cybersecurity events?"]
[]
[]
[]
[null,"5.3.2.7",0,"Is monitoring for unauthorized personnel, connections, devices, and software performed?"]
[]
[]
[]
[null,"5.3.2.8",0,"Are vulnerability scans performed?"]
[]
[]
[]
["5.3.3","Detection Processes"]
[]
[null,"5.3.3.1",0,"Are roles and responsibilities for detection well defined to ensure accountability?"]
[]
[]
[]
[null,"5.3.3.2",0,"Do detection activities comply with all applicable requirements?"]
[]
[]
[]
[null,"5.3.3.3",0,"Are detection processes tested?"]
[]
[]
[]
[null,"5.3.3.4",0,"Is event detection information communicated to appropriate parties?"]
[]
[]
[]
[null,"5.3.3.5",0,"Are detection processes continuously improved?"]

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[]
[5,"Cybersecurity Management Profile"]
[]
[null,5.4,null,"Response"]
[]
[]
["5.4.1","Response Planning"]
[]
[null,"5.4.1.1",0,"Are predefined plans/policies for responding to cybersecurity incidents in place?"]
[]
[]
[]
[null,"5.4.1.2",0,"Do cyber response plans/policies include threshold criteria for activation of response protocols?"]
[]
[]
[]
[null,"5.4.1.3",0,"Is there an IT service provider or an internal cyber team responsible for immediately responding to, coordinating and/or managing cyber incidents?"]
[]
[]
[]
[null,"5.4.1.4",0,"Should the primary IT systems become inoperable, is there access to alternative systems for performing mission essential IT functions?"]
[]
[]
[]
["5.4.2","Communications"]
[]
[null,"5.4.2.1",0,"Do personnel know their roles, responsibilities, and order of operations when a response is needed?"]
[]
[]
[]
[null,"5.4.2.2",0,"Are cybersecurity event logs maintained, routinely reviewed, and reported on?"]
[]
[]
[]
[null,"5.4.2.3",0,"Are events reported consistent with established criteria and other requirements?"]
[]
[]
[]
[null,"5.4.2.4",0,"Does voluntary information sharing occur with external stakeholders to achieve broader cybersecurity situational awareness?"]
[]
[]
[]
["5.4.3","Analysis"]
[]
[null,"5.4.3.1",0,"Are notifications from detection systems investigated? "]
[]
[]
[]
[null,"5.4.3.2",0,"Is the impact of the incident understood?"]
[]
[]
[]
[null,"5.4.3.3",0,"Are forensics performed?"]
[]
[]
[]
[null,"5.4.3.4",0,"Are incidents categorized consistent with response plans?"]
[]
[]
[]
["5.4.4","Mitigation"]
[]
[null,"5.4.4.1",0,"Are incidents contained?"]
[]
[]
[]
[null,"5.4.4.2",0,"Are incidents mitigated?"]
[]
[]
[]
[null,"5.4.4.3",0,"Are newly identified vulnerabilities mitigated or documented as accepted risks?"]
[]
[]
[]
["5.4.5","Improvements"]
[]
[null,"5.4.5.1",0,"Is incident response included in cybersecurity drills and exercises?"]
[]
[]
[]
[null,"5.4.5.2",0,"Do response plans incorporate lessons learned from drills, exercises, and real world events?"]
[]
[]
[]
[null,"5.4.5.3",0,"Are response strategies updated based on industry best practices and lessons learned from drills, exercises, and real world events?"]

{"sheet":"5.5","index":40,"n_rows":29,"n_cols":4,"rows_kept":29,"cut":false,"hidden":true,"merged":[]}
[]
[5,"Cybersecurity Management Profile"]
[]
[null,5.5,null,"Recovery"]
[]
[]
["5.5.1","Recovery Planning"]
[]
[null,"5.5.1.1",0,"Are predefined plans/policies for recovering from cybersecurity incidents in place?"]
[]
[]
[]
[null,"5.5.1.2",0,"Is the cyber recovery plan executed consistent with a defined activation threshold?"]
[]
[]
[]
["5.5.2","Improvements"]
[]
[null,"5.5.2.1",0,"Do cyber recovery plans incorporate lessons learned from drills, exercises and real world events?"]
[]
[]
[]
[null,"5.5.2.2",0,"Are recovery plans updated based on industry best practices and lessons learned from drills, exercises, and real world events?"]
[]
[]
[]
["5.5.3","Communications"]
[]
[null,"5.5.3.2",0,"Are recovery activities communicated to internal stakeholders and executive and management teams?"]

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[]
[]
[null,null,"Results"]
[]
[null,null,"The responses entered into this assessment tool are tabulated into an overall Vulnerability and Resilience Score, ranging from zero to 100. A score closer to 100 indicates the facility or asset being assessed has low overall vulnerability and is highly resilient.\n\nThe Vulnerability and Resilience Score is composed of four equally weighted subscores, which reflect the four major sections of the RIST. Each subscore is also reported on a scale from zero to 100, and represents the percentage of available points received within each section. For further detail on the make-up of the subscores, click the Show/Hide Details button.\n\nTo return to any specific section of the RIST, click the Menu button at the top of this page. Scores can be exported to a single, simplified spreadsheet using the Export Results button at the bottom of this page. This exported sheet can be imported into the multiple assessment viewer to compare a group of assets (e.g., within a coalition or region)."]
[]
[]
[]
[null,null,"Vulnerability and Resilience Score",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,{"$f":"AVERAGE(Scoring!H11,Scoring!H17,Scoring!H26,Scoring!H37)","v":0}]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,{"$f":"1-T9","v":1}]
[null,null,null,null,{"$f":"T9","v":0},null,null,null,null,null,null,null,null,null,null,null,null,null,null,"OVERALL"]
[]
[]
[]
[null,null,{"$f":"IF(PROGRESS < 1,\"NOTICE: Not all survey questions have been completed (\" & ROUND(1-PROGRESS, 3)*100 & \"% Remaining).\nResults may not accurately reflect the vulnerability and resilience of the facility.\",\"\")","v":"NOTICE: Not all survey questions have been completed (100% Remaining).\nResults may not accurately reflect the vulnerability and resilience of the facility."}]
[]
[]
[]
[]
[]
[]
[]
[]
[null,null,null,null,null,null,null,null,null,"Resilience",null,null,null,null,null,null,null,null,null,"Physical Security"]
[null,2,"Resilience Management Profile",null,null,null,null,{"$f":"Scoring!H11","v":0},null,{"$f":"1-H25","v":1},null,3,"Physical Security Management Profile",null,null,null,null,{"$f":"Scoring!H17","v":0},null,{"$f":"1-R25","v":1}]
[null,2.1,"Business Continuity",null,null,null,null,{"$f":"Scoring!H12","v":0},null,null,null,3.1,"Physical Security Organization, Policies, and Plans",null,null,null,null,{"$f":"Scoring!H18","v":0}]
[null,2.2000000000000002,"Emergency Management",null,null,null,null,{"$f":"Scoring!H13","v":0},null,null,null,3.2,"Personnel Surety",null,null,null,null,{"$f":"Scoring!H19","v":0}]
[null,2.2999999999999998,"Information Sharing",null,null,null,null,{"$f":"Scoring!H14","v":0},null,null,null,3.3,"Security Training",null,null,null,null,{"$f":"Scoring!H20","v":0}]
[null,2.4,"Climate Change",null,null,null,null,{"$f":"Scoring!H15","v":0},null,null,null,3.4,"Security Force Profile",null,null,null,null,{"$f":"Scoring!H21","v":0}]
[null,null,null,null,null,null,null,null,null,null,null,3.5,"Physical Access Control",null,null,null,null,{"$f":"Scoring!H22","v":0}]
[null,null,null,null,null,null,null,null,null,null,null,3.6,"Lighting, Surveillance, and Intrusion Detection",null,null,null,null,{"$f":"Scoring!H23","v":0}]
[null,null,null,null,null,null,null,null,null,null,null,3.7,"Badging and Internal Security",null,null,null,null,{"$f":"Scoring!H24","v":0}]
[]
[]
[]
[]
[]
[]
[]
[]
[null,null,null,null,null,null,null,null,null,"Dependencies",null,null,null,null,null,null,null,null,null,"Cybersecurity"]
[null,4,"Critical Dependencies",null,null,null,null,{"$f":"Scoring!H26","v":0},null,{"$f":"1-H42","v":1},null,5,"Cybersecurity Management",null,null,null,null,{"$f":"Scoring!H37","v":0},null,{"$f":"1-R42","v":1}]
[null,4.0999999999999996,"General Dependencies",null,null,null,null,{"$f":"Scoring!H27","v":0},null,null,null,5.0999999999999996,"Identify",null,null,null,null,{"$f":"Scoring!H38","v":0}]
[null,4.2,"Information Technology (IT)",null,null,null,null,{"$f":"Scoring!H28","v":0},null,null,null,5.2,"Protect",null,null,null,null,{"$f":"Scoring!H39","v":0}]
[null,4.3,"Electricity",null,null,null,null,{"$f":"Scoring!H29","v":0},null,null,null,5.3,"Detect",null,null,null,null,{"$f":"Scoring!H40","v":0}]
[null,4.4000000000000004,"Natural Gas",null,null,null,null,{"$f":"Scoring!H30","v":0},null,null,null,5.4,"Response",null,null,null,null,{"$f":"Scoring!H41","v":0}]
[null,4.5,"Water",null,null,null,null,{"$f":"Scoring!H31","v":0},null,null,null,5.5,"Recovery",null,null,null,null,{"$f":"Scoring!H42","v":0}]
[null,4.5999999999999996,"Wastewater and Waste Disposal",null,null,null,null,{"$f":"Scoring!H32","v":0}]
[null,4.7,"Communications",null,null,null,null,{"$f":"Scoring!H33","v":0}]
[null,4.8,"Transportation",null,null,null,null,{"$f":"Scoring!H34","v":0}]
[null,4.9000000000000004,"Critical Products",null,null,null,null,{"$f":"Scoring!H35","v":0}]

{"sheet":"Scoring","index":42,"n_rows":60,"n_cols":242,"rows_kept":60,"cut":false,"hidden":true,"merged":[[9,9,9,10],[9,18,9,19],[9,234,9,235]]}
[null,null,null,null,null,null,null,null,null,null,null,1,"Facility/Asset Characterization",null,null,null,null,null,null,null,2,"Resilience Management Profile",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,3,"Physical Security Management Profile",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,4,"Critical Dependencies",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,5,"Cybersecurity Management Profile"]
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[]
[]
[]
[null,null,null,null,null,null,null,null,null,null,null,1.1000000000000001,"General Characterization",null,null,null,null,null,null,null,2.1,"Business Continuity",null,null,null,null,null,null,null,2.2000000000000002,"Emergency Management",null,null,null,null,null,null,null,2.2999999999999998,"Information Sharing",null,null,null,null,null,null,null,2.4,"Climate Change",null,null,null,null,null,null,null,3.1,"Physical Security Organization, Policies, and Plans",null,null,null,null,null,null,null,3.2,"Personnel Surety",null,null,null,null,null,null,null,3.3,"Security Training",null,null,null,null,null,null,null,3.4,"Security Force Profile",null,null,null,null,null,null,null,3.5,"Physical Access Control",null,null,null,null,null,null,null,3.6,"Lighting, Surveillance, and Intrusion Detection",null,null,null,null,null,null,null,3.7,"Badging and Internal Security",null,null,null,null,null,null,null,4.0999999999999996,"General Dependencies",null,null,null,null,null,null,null,4.2,"Information Technology (IT)",null,null,null,null,null,null,null,4.3,"Electricity",null,null,null,null,null,null,null,4.4000000000000004,"Natural Gas",null,null,null,null,null,null,null,4.5,"Water",null,null,null,null,null,null,null,4.5999999999999996,"Wastewater and Waste Disposal",null,null,null,null,null,null,null,4.7,"Communications",null,null,null,null,null,null,null,4.8,"Transportation",null,null,null,null,null,null,null,4.9000000000000004,"Critical Products",null,null,null,null,null,null,null,5.0999999999999996,"Identify",null,null,null,null,null,null,null,5.2,"Protect",null,null,null,null,null,null,null,5.3,"Detect",null,null,null,null,null,null,null,5.4,"Response",null,null,null,null,null,null,null,5.5,"Recovery"]
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["1.1.6",0,"x"]
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["2.1.1    ",0,0]
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["2.1.2.1  ",0,0]
["2.1.2.2  ",0,0]
["2.1.2.3  ",0,0]
["2.1.2.4  ",0,0]
["2.1.2.5  ",0,0]
["2.1.2.6  ",0,0]
["2.1.2.7  ",0,0]
["2.1.3    ",0,0]
["2.1.4    ",0,0]
["2.1.5    ",0,0]
["2.1.6    ",0,0]
["2.2.1",0,"x"]
["2.2.2",0,0]
["2.2.3",0,0]
["2.2.3.1",0,0]
["2.2.4",0,0]
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["4.2.1",0,"x"]
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["4.2.11",3,0.5]
["4.2.12",4,0.75]
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