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[]
["Kategori",null,"Beskrivelse","Fyll inn:"]
["ROS av:",null,"Kva system/prosess skal det gjennomførast ROS av? "]
["Avgrensning/Scope",null,"Kva avgrensningar er gjort? Kva er ikkje omfatta? "]
["Tidsrom for gjennomføring:"]
["Deltakarar: "]
[]
["Korleis nytta dette verktøyet:",null,"Denne Excel-malen kan fungera som eit støttedokument i ROS-arbeidsmøte fram til ROS-en kan registererast i eit digitalt  internkontollsystem.  \n\nArket \"Risikovurdering\" kan nyttast i ROS-arbeidsmøte til å identifisera risikohendingar, skildra årsaka til hendinga og vurdera sannsyn og konsekvens av hendendinga. Arket \"Risikokriterier\" kan nyttast som støtte i å vurdera sannsyn og konsekvens. \n\nRisikomatrisa nedanfor gir eit oversyn på kor kritiske dei identifiserte risikoane er. "]
[]
[]
[]
[]
[]
[]
[]
[null,null,"Risikomatrise"]
[]
["Sannsyn","Svært høg",{"$f":"Dataark!AE6","v":""},{"$f":"Dataark!AF6","v":""},{"$f":"Dataark!AG6","v":""},{"$f":"Dataark!AH6","v":""},{"$f":"Dataark!AI6","v":""}]
[null,"Høg",{"$f":"Dataark!AE7","v":""},{"$f":"Dataark!AF7","v":""},{"$f":"Dataark!AG7","v":""},{"$f":"Dataark!AH7","v":""},{"$f":"Dataark!AI7","v":""}]
[null,"Middels",{"$f":"Dataark!AE8","v":""},{"$f":"Dataark!AF8","v":""},{"$f":"Dataark!AG8","v":""},{"$f":"Dataark!AH8","v":""},{"$f":"Dataark!AI8","v":""}]
[null,"Låg",{"$f":"Dataark!AE9","v":""},{"$f":"Dataark!AF9","v":""},{"$f":"Dataark!AG9","v":""},{"$f":"Dataark!AH9","v":""},{"$f":"Dataark!AI9","v":""}]
[null,"Veldig låg",{"$f":"Dataark!AE10","v":""},{"$f":"Dataark!AF10","v":""},{"$f":"Dataark!AG10","v":""},{"$f":"Dataark!AH10","v":""},{"$f":"Dataark!AI10","v":""}]
[null,null,"Svært liten","Liten","Middels","Stor","Svært stor"]
[]
[null,null,"Konsekvens"]

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["Eksempel"]
[null,"Nummer","Kategori","Tittel","Skildring","Årsak","Nosituasjon","Bakgrunn for vurdering av sannsyn og konsekvens","Sannsyn","Konsekvens","Risiko","Moglege nye tiltak","Ansvarleg","Frist","Inkluderast i DPIA? "]
["Skildring",null,"Er riskoen av teknisk eller funksjonell art? Tekniske risikoar omfattar til dømes risiko knytt til sjølve systemet, medan funksjonell risiko omfattar prosessar, prosedyrar og bruken av systemet. ","Skriv ein kort og overordna tittel for å skildra risikoen","Skildringa skal svara ut følgande spørsmål: \n1. Kva skjer med systemet eller opplysningane? \n2. Kva konsekvensar har hendinga? ","Kva er årsaka til hendinga? ","Nosituasjon skal svara ut følgjande spørsmål: \n1. Kva tekniske eller organisatoriske tiltak er etablert for å hindra denne hendinga? \n2. Har hendinga skjedd tidlegare, eventuelt kor ofte skjer dette? ","Kva er bakgrunnen for vurderinga av sannsyn? \n\nKva er bakgrunnen for vurderinga av konsekvensen? ","Vurder frå 1-5","Vurder frå 1-5",null,"Kva slags nye tiltak kan implementerast for å redusere sannsynet? ","Kven er ansvarleg for å utføra tiltaket? Vedkommande kan delegere ansvaret vidare ved behov. ","Kva er frista for utføring av tiltaket? ","Omfattar hendinga personvern? "]
["Døme","Døme: R1","Funksjonell ","Helsepersonell har tilgang til informasjon uten tenleg behov grunna manglande oversikt over tilgangar ","Helsepersonell har tilgang på helse- og personopplysningar dei ikkje har tenleg behov for å sjå. Konsekvensen av denne hendinga er potensielt at helsepersonell utnyttar sin tilgang og snokar i informasjon dei ikkje har tenleg behov for, og det kan medføre brot på personopplysningsloven .","Manglande oversyn over kven som har kva slags tilganger","Eksisterande tiltak: \n- Det er rutinar for å søke om tilgangar for nytilsette\n- Det manglar rutinar for å avslutte tilgangar når nokon sluttar/byttar avdeling\n- Det manglar rutine for å gjennomgå og oppdatere tilgangsoversyn\n\nDet er kjent at fleire har tilgang utover tenleg behov fordi dei framleis har tilgangar frå sine gamle avdelingar. Det er usikkert kor mange det gjeld. ","Sannsyn for hendinga vert vurdert til høg, fordi det er kjent at dette har skjedd ved fleire anledningar og ein manglar oversyn over kor mange dette gjeld. I tillegg aukar sannsynet fordi det ikkje eksisterar tilstrekkeleg tiltak for å hindre hendinga, til dømes:\n- Manglande rutinar for avslutting av tilgangar\n- Manglande rutine for å gjennomgå og oppdatere tilgangsoversyn\n\nKonsekvensen av at helsepersonell har tilgang på informasjon uten tenleg behov, kan potensielt føre til brot på personopplysningsloven. Dette vert vurdert til moderat konsekvens. ",2,3,{"$f":"IF(I4*J4=0,\"\",VLOOKUP(I4,Dataark!$AE$16:$AJ$21,Risikovurdering!J4+1,TRUE))","v":"Middels"},"Etablere rutiner for å avslutte tilganger når noen slutter/bytter avdeling. Dette kan være nærmeste leders ansvar og sørge for og bør inkluderes i deres ansvarsbeskrivelse. \n\nEtablere rutine for å jevnlig gjennomgå tilganger. Det bør vurderes hvem som skal ha denne rollen og frekvensen av gjennomgangene. ","Person X","2021-05-31"]
[]
[null,"Nummer","Kategori","Tittel","Skildring","Årsak","Nosituasjon","Bakgrunn for vurdering av sannsyn og konsekvens","Sannsyn","Konsekvens","Risiko","Moglege nye tiltak","Ansvarleg","Frist","Inkluderast i DPIA? "]
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[null,"R99",null,null,null,null,null,null,null,null,{"$f":"IF(I105*J105=0,\"\",VLOOKUP(I105,Dataark!$AE$16:$AJ$21,Risikovurdering!J105+1,TRUE))","v":""}]
[null,"R100",null,null,null,null,null,null,null,null,{"$f":"IF(I106*J106=0,\"\",VLOOKUP(I106,Dataark!$AE$16:$AJ$21,Risikovurdering!J106+1,TRUE))","v":""}]

{"sheet":"Risikokriterie","index":2,"n_rows":17,"n_cols":7,"rows_kept":17,"cut":false,"hidden":false,"merged":[]}
["Sannsynmatrise:"]
["Eksempel på tilnærming","Ubetydeleg (1)","Låg (2)","Middels (3)","Høg (4)","Svært høg (5)"]
["Frekvens (kor ofte oppstår hendinga)"," ","Forventast å inntreffe årleg","Forventast å inntreffe minst kvartalsvis","Forventast å inntreffe tilnærma månadleg","Forventast å inntreffe vekentleg"]
[null,"Hendinga kan oppstå under heilt spesielle omstende (inntreff med 0-5 % sannsyn)","Hendinga kan oppstå under sjeldne omstende (inntreffer med 5-10 % sannsyn)","Hendinga kan oppstå under nokon omstende (inntreff med 10-30 % sannsyn)","Hendinga kan oppstå under fleire omstende (inntreff med 30-70 % sannsyn)","Hendinga kan oppstå under fleire omstende (inntreff med 70-100 % sannsyn)"]
["Etterleving av tiltak (I kva grad eksisterar/vert tiltaka fulgt?)","- Sikkerheitstiltak er etablert og fungerar etter hensikt\n- Tiltaka kan vanskeleg omgås/brytast av eigne tilsette\n- Eksternt personell kan ikkje omgå/bryta tiltaka","- Sikkerheitstiltak er etablert, men det er ikkje etterprøvd om dei fungerar etter hensikt. \n- Tiltaka kan vanskeleg omgås/brytast av eigne tilsette\n- Eksternt personell kan ikkje omgå/bryte tiltaka ","- Sikkerheitstiltak er ikkje fullt ut etablert etter sikkerheitsbehovet.\n- Tiltaka kan omgås/brytast av eigne tilsette med små til normale ressursar \n- Eksternt personell treng gode ressursar, og god/fullstendig kjennskap til tiltaka for å omgå/bryte desse","- Sikkerheitstiltak er ikkje fullt ut etablert, eller fungerar ikkje etter hensikta\n- Eigne tilsette treng berre små til normale ressursar for å omgå/bryte tiltaka\n- Eksternt personell treng normal kjennskap til tiltaka, i tillegg til små/normale ressursar for å bryte tiltaka","- Sikkerheitstiltak er ikkje etablert, eller sikkerheitstiltak er sterkt avhengig av at ei eller fleire manuelle rutinar vert fulgt\n- Eigne tilsette treng ikkje kjennskap til tiltaka, eller det kan oppstå hendingar som følgje av uhell eller uaktsomheit. \n- Utanforståande/eksternt personell treng ikkje kjennskap til tiltaka, eller kan omgå utan særskilt kompetanse/kapasitet/motivasjon"]
[]
["Konsekvensmatrise:"]
["Eksempel på tilnærming","Ubetydeleg (1)","Mindre alvorleg (2)","Alvorleg (3)","Svært alvorlig (4)","Kritisk (5)"]
["Konfidensialitet","Enkelte tilsette i Voss herad får tilgang til open informasjon dei ikkje har tenleg behov for. ","Grupper av tilsette i Voss herad eller eksterne får tilgang til open informasjon som ikkje er offentleggjort. ","Uvedkomande får tilgang til intern informasjon, men offentleggjering av informasjonen har lavt skadepotensial. Mogleg kritikk frå tilsynsorgan","Uvedkomande får tilgang til intern eller sikker informasjon som kan misbrukast til  skade for heradet, samfunnet eller tredjepartar. Alvorlege brot på/avvik frå lov/forskrift. Kritikk frå tilsynsorgan, varsel om moglege sanksjonar. Potensielt erstatningsansvar ovanfor tredjepart","Omfattande lekkasje av sikker informasjon som kan misbrukast til alvorleg skade for heradet, samfunnet eller tredjepartar. Svært alvorlege brot på/avvik frå lov og forskrift. Sanksjonar fra tilsynsorgan. Erstatningsansvar ovanfor tredjepart."]
["Integritet",null,"Mindre avvik eller manglar i registrert informasjon, men lavt skadepotensial for heradet eller tredjepart. Mindre kvalitetsavvik.","Feil eller manglar i registrert informasjon eller styringsdata kan føre til skade for heradet eller tredjepart. Ikkje avvik frå lov/forskrift. Moderat kvalitetsavvik","Feil eller manglar i registrert informasjon eller styringsdata kan gje alvorleg skadeverknad for heradet, samfunn eller tredjepart. Alvorlege brot på/avvik frå lov/forskrift. Kritikk frå tilsynsorgan, varsel om moglege sanksjonar. Potensielt erstatningsansvar ovanfor tredjepart","Feil eller manglar i registrert informasjon eller styringsdata kan gje svært alvorleg skadeverknad for heradet, samfunn eller tredjepart. Svært alvorlege brot på/avvik frå lov og forskrift. Sanksjonar fra tilsynsorgan. Erstatningsansvar ovanfor tredjepart. ",""]
["Tilgjengelegheit - Tilsett","Ubetydeleg nedetid eller utilgjengelegheit av data. ","Overskriding av akseptabel nedetid for systemet. Enkelte tilsette vert hindra i å utføre daglege arbeidsoppgåver i ei kort periode. Intet tap av styring","Overskriding av akseptabel nedetid for systemet. Fleire tilsette vert hindra i å utføre daglege arbeidsoppgåver i ei kort periode.  ","Alvorleg overskriding av akseptabel nedetid for system eller prosess. Mange tilsette vert hindra i å utføre viktige arbeidsoppgåver i ei kort periode, eller fleire tilsette vert hindra i ei lang periode. Viktige historiske data kan gjenskapast etter hendinga. Midlertidig tap av styring og kontroll","Svært alvorleg overskriding av akseptabel nedetid for system eller prosess. Mange tilsette vert hindra i å utføre viktige arbeidsoppgåver i ei lang periode. Tidskritiske arbeidsoppgåver kan ikkje utførast. Viktige historiske data går tapt. Langvarig tap av styring og kontroll."]
["Voss herad sitt omdøme","Ubetydeleg påverknad, ingen medieoppslag ","Førespurnad frå media utan negative oppslag ","Mindre/kortvarige oppslag i media. Moderat kritikk frå revisjon/tilsynsorgan","Negative oppslag i media over fleire dagar, stort engasjement frå politisk nivå. Betydeleg kritikk frå revisjon/tilsynsorgan","Langvarige og svært negative oppslag i media, omfattande engasjement frå politisk nivå. Sterk kritikk frå revisjon/tilsynsorgan."]
["Materielle verdier og økonomi (Voss herad)","Ubetydeleg økonomisk tap/ <25.000 Påvirkar ikkje driftsbudsjettet","Avgrensa økonomisk tap/25.000-50.000 Overskriding driftsbudsjett  < 0,5 % ","Moderat økonomisk tap/50.000-100.000 Overskriding driftsbudsjett 0,5-1,5 %","Alvorleg økonomisk tap/100.000-500.000 Overskriding driftsbudsjett 1,5-3% ","Svært alvorleg økonomisk tap >500.000 Overskriding driftsbudsjett > 3 % "]
["Tenesta til brukar - Drift","Ubetydeleg påverknad på kontinuitet i tenesteproduksjon. Ubetydeleg brot på/avvik frå lov og forskrift/politiske vedtak, ingen anmerkningar frå tilsynsorgan. Ubetydeleg kvalitetsavvik","Liten påverknad på kontinuitet i tenesteproduksjon. Små brot på /avvik frå lov og forskrift/politiske vedtak, ingen anmerkningar frå tilsynsorgan. Mindre kvalitetsavvik","Moderat påverknad på kontinuitet i tenesteproduksjon. Moderate brot på /avvik frå lov og forskrift/politiske vedtak, anmerkning fra tilsynsorgan - men ingen sanksjonar. Moderat kvalitetsavvik","Alvorleg påverknad på kontinuitet i tenesteproduksjon. Alvorlege brot /avvik frå lov og forskrift/politiske vedtak, anmerknad frå tilsynsorgan-varsel om moglege sanksjonar. Alvorleg kvalitetsavvik","Svært alvorleg påverknad på kontinuitet i tenesteproduksjon. Svært alvorlege brot på/avvik frå lov og forskrift/politiske vedtak, sanksjonar fra tilsynsorgan. Svært alvorleg kvalitetsavvik"]
["HMS Fysisk/psykisk skade","Kan medføre behov for enkel førstehjelp","Behandling eller oppfølgning av medisinsk personell ","Fråvær eller krev alternativt arbeid ","Langvarig fråvær og/eller alvorlege personskadar ","Dødsfall"]
["HMS Ytre miljø","Ingen målbar miljøskade ","Kortvarig, reversibel miljøskade","Langvarig, reversibel miljøskade","Irreversibel miljøskade","Alvorleg, irreversibel miljøskade"]
["Tenesta til brukar - Liv og helse","Fysisk/psykisk skade som kan medføre behov for enkel førstehjelp. Ingen endring i funksjonsnivå.","Fysisk/psykisk skade som kan kreve behandling eller oppfølgning av medisinsk personell. Mindre, forbigåande funksjonsnedsetting","Moderat, fysisk/psykisk skade. Moderat forbigåande funksjonsnedsetting","Alvorleg, fysisk/psykisk skade. Alvorleg, men forbigåande, funksjonsnedsetting","Alvorleg, varig skade (mèn) eller dødsfall"]

{"sheet":"Tema for risikovurdering","index":3,"n_rows":10,"n_cols":2,"rows_kept":10,"cut":false,"hidden":false,"merged":[[0,0,0,1]]}
["Temaer for diskusjon i risikovurdering"]
[]
[]
["Tema","Problemstillingar og hendingar"]
["Konfidensialitet og innsyn","* Skal dei registrerte sjølv kunne sjå informasjon i løysinga?\n- Skal dei kunne sjå informasjon om andre personar enn seg sjølv? Korleis får dei i så fall tilgang til dette? Vil opplysningar om kven som skal sjå informasjon om kven alltid være korrekte?\n- Kva informasjon får dei registrerte sjå? Har me tilstrekkelig sikker pålogging som gjer det vanskeleg for uvedkommande å få tilgang til andre sin informasjon?\n* Er løysinga beskytta mot avlytting av nettverkstrafikk?"]
["Tilgangsstyring","* Finnes det ulike grupper av saksbehandlarar/brukarar/tilsette som skal nytte løysinga?\n- Er det problematisk om alle brukarar kan sjå all informasjon i løysinga?\n- Er det problematisk om alle brukarar har tilgang til å gjere alle endringar eller legge inn ny informasjon?"]
["Personvernrettigheiter","* Kan dei registrerte kreve innsyn i opplysningar?\n- Korleis vil me handtere eit krav om innsyn i alle personopplysningar om ein person?\n* Er dei registrerte informert om behandlinga løysinga vert nytta til, gjennom personvernerklæring eller annan informasjon?"]
["Påliteleg informasjon (integritet)","* Kva konsekvensar kan det få om informasjon i løysinga ikkje er riktig?\n- Har me rutiner som gjer at me oppdagar moglege feil før dei får konsekvensar?\n- Har me rutiner som sikrar at me ikkje legg inn feil informasjon?"]
["Tilgjengelegheit","* Kva konsekvensar kan det få hvis hele løysinga er utilgjengeleg?\n- Kor langt tidsrom klarer me oss uten løysinga? Vil me levere med redusert kvalitet, eller kan me ikkje levere i det hele tatt?\n- Har me planar og rutinar for å handtere at løysinga fell bort?\n* Kva konsekvensar kan det få hvis noko informasjon er midlertidig utilgjengeleg eller går tapt?"]
["Bruk og misbruk","* Er det problematisk om løysinga vert nytta til andre formål enn det det er meint for?\n- Har me gitt rettleiing om kva løysinga skal nyttast til?\n- Finns det andre behov brukarar kan tenkast å nytte løysinga for å dekke? Har me rettleiing som peikar brukarane i riktig retning?"]

{"sheet":"Hjelpespørsmål","index":4,"n_rows":31,"n_cols":1,"rows_kept":31,"cut":false,"hidden":false,"merged":[]}
[]
["Hjelpespørsmål til gjennomføring av risiko- og sårbarheitsvurdering (ROS-vurdering) "]
[]
["Identifisere og kartlegge"]
["·         Har me oversyn over kva type informasjon systemet behandlar? (Taushetsbelagt, verksemdskritisk,  særlege kategoriar av personopplysningar etc.)"]
["o   Er det behov for særlege vurderingar av sikkerheitsnivå basert på informasjonen som vert lagra/behandlast?"]
["·         Er behandlinga av eventuelle personopplysningar/særlige kategoriar av personopplysningar registrert i Voss herad sin behandlingsprotokoll?"]
["·         Har me oversyn over IT-arkitekturen, herunder maskinvare, dataflyt, integrasjonar etc.?"]
["·         Har me oversyn over kven som er involvert i behandlinga av informasjonen? Underleverandørar, andre byrådsavdelingar, personell etc."]
["·         Har me etablert tilstrekkelege driftsavtalar/driftsorganisasjon som sikrar at systemet vert vedlikehaldt?"]
["·         Eksisterar det ei databehandleravtale?"]
["·         Får dei tilsette opplæring kring personvern, informasjonssikkerheit, og eventuelle risikoar ved bruk av systemet/prosessen?"]
["Tilgangsstyring"]
["·         Har me definert rollar som er i tråd med brukarane sitt tenlege behov for informasjon?"]
["o   Har me eigne administratorar med utvida rettigheiter?"]
["·         Har me etablert rutinar for å sikra at brukerkontoar vert korrekt oppretta og avslutta/sletta når vedkommande sluttar/byttar stilling?"]
["·         Har me etablert rutinar for revisjon av tilgangar?"]
["·         Har me etablert rutinar som sikrar at misbruk av brukarkonto, til dømes til snoking eller anna, vert avdekka?"]
["Beskytte og opprette"]
["·         Er det etablert tilstrekkeleg sikkerheitskopi av system og informasjon, som sikrar at data kan gjenopprettast etter ei hending?"]
["·         Er det etablert tilstrekkelege rutinar som sikrar at naudsynte endringar/oppdateringar vert gjennomført og at desse har tilstrekkeleg kvalitet før det vert satt i verk? (Til dømes gjennom testrutinar.)"]
["·         Er kommunikasjon/dataoverføring mellom systemet og klienten kryptert?"]
["·        Om tenesta er heilt/delvis utkontraktert; har me etablert tiltak som sikrar at leverandøren gjennomfører sine plikter i forhold til drift, tilgjenge og sikkerheit?"]
["·         Om IT-systemet samhandlar med andre system (internt eller eksternt); er kommunikasjonen/dataoverføringa kryptert?"]
["Oppdage"]
["·         Er det rutinar for å sikra at program- og maskinvare til ei kvar tid er oppdatert?"]
["·         Er det etablert rutinar som sikrar at sikkerheitsbrot vert oppdaga?"]
["·         Vert det gjennomført sikkerheitstestar/IT-revisjonar av systemet?"]
["Handtere og gjenopprette"]
["·         Er det etablert rutinar for kva avdelinga skal gjere ved korte eller lengre bortfall av systemet/prosessen?"]
["·         Kva er konsekvensen av at systemet/prosessen/informasjonen er utilgjengeleg over kortare eller lengre periodar?"]

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[]
[]
[]
[null,null,"Kategori"]
[null,null,"Funksjonell"]
[null,null,"Teknisk"]
[null,null,"Organisatorisk"]
[null,null,"Kompetanse"]
[null,null,"Kultur"]

{"sheet":"Dataark","index":6,"n_rows":192,"n_cols":36,"rows_kept":192,"cut":false,"hidden":true,"merged":[[1,1,1,25],[1,29,1,34],[0,0,0,5],[14,31,14,35],[16,29,20,29]]}
["Passord for endring: bergenkommune"]
[null,"Datamatrise",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,"Risikomatrise"]
["Konsekvens","Svært liten","Svært liten","Svært liten","Svært liten","Svært liten","Liten","Liten","Liten","Liten","Liten","Middels","Middels","Middels","Middels","Middels","Stor","Stor","Stor","Stor","Stor","Svært stor","Svært stor","Svært stor","Svært stor","Svært stor"]
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