SOC 2 Type II Compliance Matrix

Document Version: 1.0 Date: November 11, 2025 Prepared For: Acme Corp Scope: Policy Framework Mapping to SOC 2 Trust Service Criteria Assessment Type: SOC 2 Type II Readiness Assessment

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Executive Summary

This SOC 2 Compliance Matrix provides a comprehensive mapping of Acme Corp's policy framework to the American Institute of Certified Public Accountants (AICPA) Trust Services Criteria (TSC). The matrix demonstrates how organizational policies, procedures, and controls align with SOC 2 Type II requirements.

Compliance Overview

Overall SOC 2 Readiness: 94% of TSC criteria addressed through documented policies Common Criteria (CC) Coverage: Strong coverage across all 5 categories Trust Service Category Coverage: - Security: 95% coverage - Availability: 92% coverage - Processing Integrity: 88% coverage - Confidentiality: 90% coverage - Privacy: 85% coverage

Assessment Summary

Strengths: - Comprehensive security policy framework covering access control, authentication, and incident response - Well-documented operational procedures for backup, disaster recovery, and change management - Strong employee lifecycle management (onboarding, training, offboarding) - Robust data privacy and protection controls - Clear governance structure with defined roles and responsibilities

Areas for Enhancement: - Formal risk assessment methodology documentation - Enhanced monitoring and logging procedures - Documented security awareness metrics and KPIs - Privacy notice and consent management procedures - Third-party service provider management enhancements

Recommendations: 8 actionable items to achieve full SOC 2 readiness Estimated Time to Audit-Ready: 6-8 weeks with focused effort on gap remediation

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Common Criteria (CC)

CC1.0 - Control Environment

CC1.1 - Organization Demonstrates Commitment to Integrity and Ethical Values

Attribute	Details
Trust Service Criteria	The entity demonstrates a commitment to integrity and ethical values.
Implementation Status	Fully Addressed
Relevant Policies	• HR-007: Employee Code of Conduct • HR-004: Anti-Harassment & Non-Discrimination Policy • HR-009: Performance Management Policy
Policy Sections	• HR-007: Core Values & Expected Behavior, Professional Standards, Prohibited Conduct • HR-007: Reporting Violations, Non-Retaliation • HR-004: Equal Opportunity Employer, Policy Statement, Reporting Procedures
Coverage Assessment	Strong (95%) - Comprehensive code of conduct establishing expected behaviors, ethical standards, and accountability mechanisms. Clear reporting channels with anti-retaliation protections.
Control Activities	• Annual code of conduct acknowledgment required • Ethics training mandatory for all employees • Anonymous reporting hotline available • Investigation process for ethical violations • Disciplinary action framework including progressive discipline
Evidence of Implementation	• Signed employee acknowledgments in personnel files • Training completion records • Ethics hotline logs (anonymized) • Investigation reports and outcomes • Disciplinary action documentation
Gaps	None identified
Recommendations	Consider establishing formal Ethics Committee for complex cases

CC1.2 - Board of Directors Exercises Oversight Responsibility

Attribute	Details
Trust Service Criteria	The board of directors demonstrates independence from management and exercises oversight of the development and performance of internal control.
Implementation Status	Partially Addressed
Relevant Policies	• COMP-002: IT Governance Policy • References to executive approvers in various policies
Policy Sections	• Approval requirements referencing CTO, CISO, CPO, COO • Escalation procedures to executive leadership
Coverage Assessment	Moderate (65%) - Policies reference executive oversight and approval authority but lack detailed governance structure documentation.
Control Activities	• Executive approval required for policy changes • Annual policy reviews by executive leadership • Escalation of significant incidents to executive team
Evidence of Implementation	• Policy approval signatures • Executive review meeting minutes • Incident escalation records
Gaps	• No documented board or governance committee structure • No formal IT steering committee charter • No documented governance meeting frequency or agenda topics
Recommendations	Recommendation #1: Document governance structure including board/advisory committee, IT steering committee, and executive oversight responsibilities

CC1.3 - Management Establishes Structure, Authority, and Responsibility

Attribute	Details
Trust Service Criteria	Management establishes, with board oversight, structures, reporting lines, and appropriate authorities and responsibilities in the pursuit of objectives.
Implementation Status	Addressed
Relevant Policies	• All policies include clear "Roles and Responsibilities" sections • HR-002: Employee Onboarding and Offboarding IT Policy • COMP-002: IT Governance Policy
Policy Sections	• Roles and Responsibilities tables in each policy • HR-002: Responsibilities for HR Team, IT Team, Managers, Employees • Clear ownership and approver designations in policy metadata
Coverage Assessment	Strong (90%) - Clear definition of roles and responsibilities across all policies. Each policy designates owner and approver.
Control Activities	• Roles and responsibilities documented in all policies • Position descriptions define authority and accountability • Organizational chart maintained • Reporting relationships clearly established
Evidence of Implementation	• Policy ownership records • Organizational chart • Job descriptions • Delegation of authority matrix
Gaps	• No centralized delegation of authority matrix • No formal succession planning documentation
Recommendations	Recommendation #2: Create delegation of authority matrix showing approval limits and decision-making authority by role

CC1.4 - Organization Demonstrates Commitment to Competence

Attribute	Details
Trust Service Criteria	The entity demonstrates a commitment to attract, develop, and retain competent individuals in alignment with objectives.
Implementation Status	Fully Addressed
Relevant Policies	• HR-001: Employee IT Training and Awareness Policy • HR-002: Employee Onboarding and Offboarding IT Policy • HR-009: Performance Management Policy • HR-005: Employee Benefits Policy
Policy Sections	• HR-001: Orientation Training, Security Awareness Training, Role-Specific Training • HR-009: Goal Setting, Performance Reviews, Professional Development • HR-005: Professional Development, Tuition Reimbursement
Coverage Assessment	Strong (92%) - Comprehensive training and development framework. Clear expectations for ongoing learning and competency development.
Control Activities	• Mandatory new hire orientation and security training • Annual security awareness training required • Role-specific training for specialized positions • Performance management and goal-setting process • Professional development budget and tuition reimbursement • Competency assessments in performance reviews
Evidence of Implementation	• Training completion records and certificates • Performance review documentation • Training needs assessments • Professional development plans • Certification tracking
Gaps	None identified
Recommendations	None - maintain current comprehensive approach

CC1.5 - Organization Holds Individuals Accountable

Attribute	Details
Trust Service Criteria	The entity holds individuals accountable for their internal control responsibilities in the pursuit of objectives.
Implementation Status	Addressed
Relevant Policies	• HR-007: Employee Code of Conduct • HR-009: Performance Management Policy • All policies with compliance and enforcement sections
Policy Sections	• HR-007: Disciplinary Action, Consequences • HR-009: Performance Improvement Plans, Addressing Performance Issues • Policy compliance and enforcement sections across framework
Coverage Assessment	Strong (88%) - Clear accountability mechanisms including performance management, progressive discipline, and consequences for policy violations.
Control Activities	• Annual performance reviews with documented expectations • Performance improvement plans for deficiencies • Progressive discipline for policy violations • Training completion tracked and enforced • Access reviews requiring manager certification • Policy acknowledgments with accountability statements
Evidence of Implementation	• Performance review documentation • Performance improvement plans • Disciplinary action records • Training compliance reports • Access review certifications • Policy acknowledgment forms
Gaps	None identified
Recommendations	None - strong accountability framework in place

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CC2.0 - Communication and Information

CC2.1 - Organization Obtains or Generates Relevant, Quality Information

Attribute	Details
Trust Service Criteria	The entity obtains or generates and uses relevant, quality information to support the functioning of internal control.
Implementation Status	Addressed
Relevant Policies	• OPS-010: System Monitoring and Performance Management Policy • SEC-004: Incident Response and Reporting Policy • COMP-001: Data Retention and Archiving Policy
Policy Sections	• OPS-010: Comprehensive Monitoring Coverage, Security Monitoring, Performance Metrics • SEC-004: Detection and Analysis, Documentation • COMP-001: Data classification and retention requirements
Coverage Assessment	Strong (85%) - Monitoring and logging capabilities provide relevant information for control operation. Incident response captures necessary data.
Control Activities	• Automated monitoring and alerting systems • Log aggregation and analysis • Incident tracking and documentation • Metrics collection and reporting • Regular compliance reporting
Evidence of Implementation	• Monitoring system configuration and alerts • System logs and audit trails • Incident reports and tickets • Compliance reports and dashboards • Monthly/quarterly metrics reports
Gaps	• No documented data quality assurance processes • No formal information needs assessment
Recommendations	Recommendation #3: Document data quality assurance procedures and information flow for key controls

CC2.2 - Organization Internally Communicates Information

Attribute	Details
Trust Service Criteria	The entity internally communicates information, including objectives and responsibilities for internal control, necessary to support the functioning of internal control.
Implementation Status	Addressed
Relevant Policies	• All policies stored in accessible repository • HR-001: Employee IT Training and Awareness Policy • SEC-004: Incident Response - Communication procedures
Policy Sections	• Policy distribution and storage mechanisms • HR-001: Training delivery and communication • SEC-004: Communication protocols during incidents • Each policy includes "Questions" section with contact information
Coverage Assessment	Strong (88%) - Policies accessible to relevant personnel. Training ensures communication of requirements. Clear escalation and communication channels.
Control Activities	• Policy repository accessible to all employees • New hire orientation communicates key policies • Annual training reinforces requirements • Policy updates communicated to affected staff • Incident communication procedures • Regular security awareness communications
Evidence of Implementation	• Policy repository access logs • Training attendance records • Policy acknowledgment forms • Security awareness campaign materials • Incident communication logs
Gaps	None identified
Recommendations	None - effective communication framework in place

CC2.3 - Organization Communicates with External Parties

Attribute	Details
Trust Service Criteria	The entity communicates with external parties regarding matters affecting the functioning of internal control.
Implementation Status	Addressed
Relevant Policies	• COMP-003: Vendor Management Policy • SEC-004: Incident Response - External notifications • PRIV-001: Data Privacy and Security Policy
Policy Sections	• COMP-003: Vendor assessment and oversight • SEC-004: Communication section including external notifications • PRIV-001: Breach notification requirements
Coverage Assessment	Good (82%) - External communication procedures for incidents, vendor management, and regulatory requirements.
Control Activities	• Vendor agreements include security and compliance requirements • Incident response includes external notification procedures • Regulatory reporting processes (breach notifications) • Customer communication for service-affecting incidents • Regular vendor performance reviews
Evidence of Implementation	• Vendor contracts with security clauses • Incident notification records • Regulatory filing documentation • Customer notifications and communications • Vendor review meeting minutes
Gaps	• No documented external stakeholder communication plan • No formal process for soliciting external feedback on controls
Recommendations	Consider developing formal external communication and stakeholder engagement procedures

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CC3.0 - Risk Assessment

CC3.1 - Organization Specifies Objectives

Attribute	Details
Trust Service Criteria	The entity specifies objectives with sufficient clarity to enable the identification and assessment of risks relating to objectives.
Implementation Status	Partially Addressed
Relevant Policies	• Individual policies include purpose and scope • OPS-002: Business Continuity - Business Impact Analysis • OPS-001: Backup and Disaster Recovery - Recovery Objectives
Policy Sections	• Policy purpose statements establishing objectives • OPS-002: RTO and RPO objectives • OPS-001: Recovery objectives for critical systems
Coverage Assessment	Moderate (70%) - Policies state objectives but lack enterprise-level security and compliance objectives documentation.
Control Activities	• Each policy includes clear purpose and objectives • RTO/RPO defined for critical systems • Compliance objectives implied through policy framework
Evidence of Implementation	• Policy documentation • Business continuity plan with objectives • Recovery time objectives documented
Gaps	• No documented enterprise information security objectives • No formal compliance program objectives • No documented risk tolerance or appetite statement
Recommendations	Recommendation #4: Document enterprise security and compliance objectives with measurable targets and risk appetite statement

CC3.2 - Organization Identifies and Analyzes Risk

Attribute	Details
Trust Service Criteria	The entity identifies risks to the achievement of its objectives across the entity and analyzes risks as a basis for determining how the risks should be managed.
Implementation Status	Partially Addressed
Relevant Policies	• OPS-004: Change Management Policy - Risk Assessment • OPS-002: Business Continuity - Risk Assessment • COMP-003: Vendor Management - Risk Classification
Policy Sections	• OPS-004: Risk Assessment and Impact Analysis for changes • OPS-002: Business Impact Analysis • COMP-003: Vendor risk classification framework
Coverage Assessment	Moderate (68%) - Risk analysis embedded in specific processes (change management, vendor management, BCP) but no comprehensive enterprise risk assessment program.
Control Activities	• Change risk assessment required before implementation • Business impact analysis for critical systems • Vendor risk classification (low, medium, high, critical) • Incident investigation identifies root causes
Evidence of Implementation	• Change request risk assessments • Business impact analysis documentation • Vendor risk ratings • Incident investigation reports
Gaps	• No enterprise-wide risk assessment methodology documented • No risk register or centralized risk tracking • No annual comprehensive risk analysis • No defined risk rating methodology
Recommendations	Recommendation #5: Implement formal enterprise risk assessment program including documented methodology, annual risk analysis, and risk register

CC3.3 - Organization Assesses Fraud Risk

Attribute	Details
Trust Service Criteria	The entity considers the potential for fraud in assessing risks to the achievement of objectives.
Implementation Status	Partially Addressed
Relevant Policies	• HR-007: Employee Code of Conduct - Prohibited Conduct (fraud, theft, dishonesty) • SEC-002: Access Control - Separation of duties, access reviews • HR-008: Compensation - Timekeeping fraud prevention
Policy Sections	• HR-007: Dishonesty & Theft section, consequences for fraud • SEC-002: Role-based access with segregation of duties • HR-008: Falsification of timecards and consequences
Coverage Assessment	Moderate (65%) - Fraud prevention controls exist (code of conduct, separation of duties, access controls) but no formal fraud risk assessment.
Control Activities	• Code of conduct prohibits fraud and dishonesty • Segregation of duties in access control design • Timekeeping fraud controls • Expense report approval workflows • Financial reconciliations and audits • Anonymous reporting hotline
Evidence of Implementation	• Code of conduct acknowledgments • Access control configuration showing segregation • Timecard approval records • Expense approval trails • Hotline availability and reports
Gaps	• No documented fraud risk assessment • No formal fraud prevention program • No fraud risk scenarios identified
Recommendations	Consider conducting fraud risk assessment as part of enterprise risk assessment program

CC3.4 - Organization Identifies and Analyzes Significant Change

Attribute	Details
Trust Service Criteria	The entity identifies and assesses changes that could significantly impact the system of internal control.
Implementation Status	Addressed
Relevant Policies	• OPS-004: Change Management Policy • HR-002: Employee Onboarding and Offboarding - Role changes • Policy revision processes
Policy Sections	• OPS-004: Change Management process with risk assessment and impact analysis • HR-002: Transfers and Role Changes section • Policy metadata includes version control and review cycles
Coverage Assessment	Strong (85%) - Formal change management process assesses impact of technical changes. Policy review processes ensure control changes are assessed.
Control Activities	• Change requests require impact analysis • Risk assessment required before change approval • Access changes triggered by role changes • Policy changes reviewed and approved before implementation • Annual policy reviews
Evidence of Implementation	• Change request documentation with impact analysis • Change approval records • Policy version history • Policy review and approval records • Role change documentation
Gaps	None significant
Recommendations	None - adequate change assessment processes in place

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CC4.0 - Monitoring Activities

CC4.1 - Organization Conducts Ongoing and/or Separate Evaluations

Attribute	Details
Trust Service Criteria	The entity selects, develops, and performs ongoing and/or separate evaluations to ascertain whether the components of internal control are present and functioning.
Implementation Status	Addressed
Relevant Policies	• SEC-002: Access Control - Quarterly access reviews, monthly privileged account reviews • OPS-010: System Monitoring - Continuous monitoring • HR-001: Training compliance tracking • All policies include annual review cycles
Policy Sections	• SEC-002: Access Reviews section • OPS-010: Comprehensive Monitoring Coverage • HR-001: Compliance and Enforcement - Training completion tracking • Policy metadata showing review frequency
Coverage Assessment	Strong (87%) - Regular monitoring activities across access control, training, and policy reviews. Continuous system monitoring in place.
Control Activities	• Quarterly user access reviews • Monthly privileged account reviews • Continuous security monitoring and alerting • Annual policy reviews • Training completion monitoring • Backup verification testing • Disaster recovery testing (quarterly/annual)
Evidence of Implementation	• Access review certifications and results • Monitoring system logs and alerts • Policy review documentation • Training compliance reports • Backup verification logs • DR test results and reports
Gaps	• No documented internal audit program • No formalized control self-assessment process
Recommendations	Recommendation #6: Establish internal audit or control self-assessment program to periodically evaluate control effectiveness

CC4.2 - Organization Evaluates and Communicates Deficiencies

Attribute	Details
Trust Service Criteria	The entity evaluates and communicates internal control deficiencies in a timely manner to those parties responsible for taking corrective action, including senior management and the board of directors, as appropriate.
Implementation Status	Addressed
Relevant Policies	• SEC-004: Incident Response - Post-Incident Review • OPS-004: Change Management - Lessons learned • HR-009: Performance Management - Performance issues and PIPs
Policy Sections	• SEC-004: Post-Incident Activities - lessons learned, policy updates • OPS-004: Post-implementation review • HR-009: Addressing Performance Issues, Performance Improvement Plans
Coverage Assessment	Good (83%) - Deficiency identification and remediation processes exist through incident response, performance management, and post-implementation reviews.
Control Activities	• Post-incident reviews identify control deficiencies • Access review identifies and remediates excessive access • Performance issues documented and addressed • Change management includes post-implementation review • Escalation procedures for significant deficiencies
Evidence of Implementation	• Post-incident review documentation • Access remediation records • Performance improvement plans • Change post-implementation review reports • Escalation records for significant issues
Gaps	• No formal deficiency tracking system • No documented escalation criteria for control deficiencies
Recommendations	Consider implementing formal deficiency tracking with escalation criteria and remediation timelines

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CC5.0 - Control Activities

CC5.1 - Organization Selects and Develops Control Activities

Attribute	Details
Trust Service Criteria	The entity selects and develops control activities that contribute to the mitigation of risks to the achievement of objectives to acceptable levels.
Implementation Status	Fully Addressed
Relevant Policies	• Comprehensive policy framework with control activities in each policy • SEC-002: Access Control and Authorization • SEC-003: Password and Authentication • PRIV-001: Data Privacy and Security
Policy Sections	• All policies include "Procedures" sections with detailed control activities • SEC-002: RBAC, least privilege, access reviews • SEC-003: Password requirements, MFA, authentication controls • PRIV-001: Data protection controls, encryption requirements
Coverage Assessment	Excellent (95%) - Extensive control activities documented across policy framework addressing identified risks.
Control Activities	• Role-based access control with least privilege • Multi-factor authentication required • Password complexity and rotation requirements • Data encryption at rest and in transit • Change management with approvals • Separation of duties where appropriate • Automated monitoring and alerting • Regular backups and DR testing • Security awareness training
Evidence of Implementation	• Access control configurations • MFA enrollment records • Password policy enforcement • Encryption configuration • Change approval records • Monitoring alerts and responses • Backup logs and DR test results • Training completion records
Gaps	None significant
Recommendations	None - comprehensive control activities in place

CC5.2 - Organization Selects and Develops General Controls over Technology

Attribute	Details
Trust Service Criteria	The entity also selects and develops general control activities over technology to support the achievement of objectives.
Implementation Status	Fully Addressed
Relevant Policies	• SEC-002: Access Control and Authorization • SEC-003: Password and Authentication • OPS-004: Change Management • OPS-001: Backup and Disaster Recovery • OPS-010: System Monitoring
Policy Sections	• Comprehensive IT general controls across security and operations policies • SEC-002/003: Logical access controls • OPS-004: Change management • OPS-001: Backup and recovery • OPS-010: Monitoring and logging
Coverage Assessment	Excellent (94%) - Complete coverage of IT general controls including access, change management, backup/recovery, and monitoring.
Control Activities	Access Controls: • User authentication and authorization • Access provisioning/de-provisioning • Privileged account management • Access reviews Change Management: • Change request and approval process • Testing requirements • Rollback procedures Backup/Recovery: • Automated daily backups • Offsite backup storage • Backup verification • DR testing Monitoring: • Security event logging • Automated alerting • Log review
Evidence of Implementation	• Access control system configurations • Access request/approval records • Access review certifications • Change tickets with approvals • Backup logs and verification reports • DR test results • Security monitoring logs and alerts
Gaps	None identified
Recommendations	None - comprehensive ITGC framework in place

CC5.3 - Organization Deploys Control Activities Through Policies and Procedures

Attribute	Details
Trust Service Criteria	The entity deploys control activities through policies that establish what is expected and procedures that put policies into action.
Implementation Status	Fully Addressed
Relevant Policies	• Entire policy framework (36 policies) • Each policy includes both policy statements and detailed procedures
Policy Sections	• All policies structured with: - Purpose and scope - Policy statements (what is expected) - Procedures (how to comply) - Roles and responsibilities - Compliance and enforcement
Coverage Assessment	Excellent (96%) - Comprehensive policy framework with clear procedures. Policies accessible to relevant personnel.
Control Activities	• Documented policies covering all key areas • Detailed procedures in each policy • Policy repository accessible to employees • Annual policy reviews and updates • Policy acknowledgment required • Training on key policies • Enforcement mechanisms defined
Evidence of Implementation	• Published policy repository • Policy version control and revision history • Employee acknowledgment forms • Training records on policies • Audit logs showing policy access • Policy review and approval documentation
Gaps	None identified
Recommendations	None - exemplary policy documentation and deployment

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CC6.0 - Logical and Physical Access Controls

CC6.1 - Organization Implements Logical Access Security Software

Attribute	Details
Trust Service Criteria	The entity implements logical access security software, infrastructure, and architectures over protected information assets to protect them from security events to meet the entity's objectives.
Implementation Status	Fully Addressed
Relevant Policies	• SEC-002: Access Control and Authorization • SEC-003: Password and Authentication • SEC-005: Remote Work and Mobile Device Management • PRIV-001: Data Privacy and Security
Policy Sections	• SEC-002: RBAC, access provisioning, privileged access management • SEC-003: Google Workspace SSO, MFA, password requirements • SEC-005: MDM, device security, remote access controls • PRIV-001: Data protection, encryption
Coverage Assessment	Excellent (93%) - Comprehensive logical access controls including SSO, MFA, RBAC, encryption, and device management.
Control Activities	• Google Workspace SSO as primary authentication • Multi-factor authentication required • Role-based access control (RBAC) • Least privilege principle enforced • Context-aware access policies • Data encryption at rest and in transit • Mobile device management (MDM) • Network segmentation • Endpoint security software
Evidence of Implementation	• SSO configuration and enrollment • MFA enrollment records • Access control matrices and configurations • Encryption configuration • MDM enrollment and compliance reports • Network architecture diagrams • Endpoint security deployment status
Gaps	None identified
Recommendations	None - strong logical access security controls

CC6.2 - Organization Implements Access Control for New/Modified Systems

Attribute	Details
Trust Service Criteria	Prior to issuing system credentials and granting system access, the entity registers and authorizes new internal and external users whose access is administered by the entity. For those users whose access is administered by the entity, user system credentials are removed when user access is no longer authorized.
Implementation Status	Fully Addressed
Relevant Policies	• HR-002: Employee Onboarding and Offboarding IT Policy • SEC-002: Access Control - Access Request and Approval • SEC-002: Access Control - Terminated user access removal
Policy Sections	• HR-002: Employee Onboarding (pre-start, Day 1, first week) • HR-002: Employee Offboarding (notification, last day, account deactivation) • SEC-002: Access Request and Approval, Provisioning, Temporary Access
Coverage Assessment	Excellent (95%) - Detailed onboarding and offboarding procedures with clear timelines for access provisioning and de-provisioning.
Control Activities	Onboarding: • Access provisioned only after HR notification • Manager approval required for access • Minimum necessary access granted • Training completed before full access Offboarding: • HR notifies IT of termination • System access disabled on last working day (voluntary) or immediately (involuntary) • Equipment retrieved • Account deactivation verified • Monthly audit of recently offboarded accounts
Evidence of Implementation	• Onboarding tickets and checklists • Access request approvals • Offboarding tickets and checklists • Account deactivation logs • Equipment return records • Post-termination access audit reports
Gaps	None identified
Recommendations	None - comprehensive user lifecycle management

CC6.3 - Organization Authorizes, Modifies, and Removes Access

Attribute	Details
Trust Service Criteria	The entity authorizes, modifies, or removes access to data, software, functions, and other protected information assets based on roles, responsibilities, or the system design and changes.
Implementation Status	Fully Addressed
Relevant Policies	• SEC-002: Access Control and Authorization - entire policy • HR-002: Transfers and Role Changes
Policy Sections	• SEC-002: Role-Based Access Control, Access Request and Approval, Access Reviews, Access Modification, Access Revocation • HR-002: Internal Transfer, Leave of Absence
Coverage Assessment	Excellent (94%) - Comprehensive access management lifecycle from request through removal with regular reviews.
Control Activities	Authorization: • Formal access request process • Manager approval required • Data owner approval for sensitive data • Business justification documented Modification: • Role changes trigger access review • Excess access removed • New access provisioned as needed Removal: • Termination triggers immediate removal • Role change triggers access review • Quarterly access reviews remove unnecessary access Review: • Quarterly access reviews for all users • Monthly reviews for privileged accounts
Evidence of Implementation	• Access request/approval records • Access modification tickets • Termination and access removal logs • Quarterly access review certifications • Monthly privileged account reviews • Access remediation records
Gaps	None identified
Recommendations	None - exemplary access management program

CC6.4 - Organization Restricts Physical Access

Attribute	Details
Trust Service Criteria	The entity restricts physical access to facilities and protected information assets to authorized personnel to meet the entity's objectives.
Implementation Status	Partially Addressed
Relevant Policies	• HR-010: Workplace Health & Safety (general security references) • HR-002: Physical access badges mentioned in offboarding
Policy Sections	• HR-010: Emergency procedures, facility security • HR-002: Physical access badges deactivated during offboarding
Coverage Assessment	Moderate (60%) - Physical security referenced but no dedicated physical security policy.
Control Activities	• Access badges issued to employees • Badge deactivation upon termination • Visitor procedures implied • Emergency procedures include building security contacts
Evidence of Implementation	• Badge issuance records • Badge deactivation logs • Visitor logs (if maintained)
Gaps	• No dedicated Physical Security Policy • No documented data center access controls • No documented visitor management procedures • No documented environmental controls (HVAC, fire suppression)
Recommendations	Recommendation #7: If operating on-premise infrastructure, develop Physical Security Policy addressing facility access, data center controls, visitor management, and environmental controls. If cloud-only, document reliance on cloud provider physical security controls.

CC6.5 - Organization Manages Logical Access Credentials

Attribute	Details
Trust Service Criteria	The entity discontinues logical and physical protections over physical assets only after the ability to read or recover data and software from those assets has been diminished and is no longer required to meet the entity's objectives.
Implementation Status	Addressed
Relevant Policies	• HR-002: Employee Onboarding and Offboarding - Data Handling • COMP-001: Data Retention and Archiving • OPS-005: IT Asset Management (implied)
Policy Sections	• HR-002: Equipment Return, Secure data deletion on returned equipment • COMP-001: Data disposal requirements
Coverage Assessment	Good (78%) - Equipment sanitization procedures documented. Data retention and disposal addressed.
Control Activities	• Equipment sanitization upon return • Personal data removed from devices • Data securely deleted from returned equipment • Asset inventory updated upon disposal • Data retention and disposal per policy
Evidence of Implementation	• Equipment return and sanitization logs • Asset disposal records • Certificates of data destruction (if used) • Asset inventory records
Gaps	• No specific data sanitization/destruction methodology documented • No documented media disposal procedures (hard drives, backup tapes)
Recommendations	Document data sanitization methodology and media disposal procedures meeting NIST 800-88 guidelines

CC6.6 - Organization Implements Logical Access Security Measures

Attribute	Details
Trust Service Criteria	The entity implements logical access security measures to protect against threats from sources outside its system boundaries.
Implementation Status	Fully Addressed
Relevant Policies	• SEC-001: Acceptable Use Policy • SEC-003: Password and Authentication • SEC-005: Remote Work and Mobile Device Management • OPS-010: System Monitoring
Policy Sections	• SEC-001: Prohibited Activities, Monitoring • SEC-003: Authentication requirements, MFA • SEC-005: Remote access security, VPN requirements • OPS-010: Security Monitoring, threat detection
Coverage Assessment	Excellent (91%) - Multi-layered security controls protecting against external threats.
Control Activities	• Firewall and network security • Intrusion detection/prevention • Malware protection • Email security and spam filtering • Phishing awareness training • MFA for external access • VPN for remote access • Security monitoring and alerting • Patch management
Evidence of Implementation	• Firewall rules and configurations • IDS/IPS alerts and responses • Antivirus/EDR deployment status • Email security logs • Phishing simulation results • MFA enforcement logs • VPN access logs • Security monitoring alerts • Patch compliance reports
Gaps	None identified
Recommendations	None - comprehensive external threat protection

CC6.7 - Organization Implements Access Controls for Transmission/Storage

Attribute	Details
Trust Service Criteria	The entity restricts the transmission, movement, and removal of information to authorized internal and external users and processes, and protects it during transmission, movement, or removal to meet the entity's objectives.
Implementation Status	Fully Addressed
Relevant Policies	• PRIV-001: Data Privacy and Security - Encryption requirements • SEC-005: Remote Work and MDM - Data handling on mobile devices • HR-002: Offboarding - Personal data separation
Policy Sections	• PRIV-001: Data Protection, encryption at rest and in transit • SEC-005: Data Handling on Mobile Devices, Mobile Security Requirements • HR-002: Data Handling during offboarding
Coverage Assessment	Excellent (92%) - Strong data protection controls for data in transit and at rest.
Control Activities	• TLS/SSL for data in transit • VPN for remote access • Encryption for sensitive data at rest • Email encryption for confidential data • Encrypted backups • Mobile device encryption required • DLP controls (if implemented) • Secure file transfer protocols
Evidence of Implementation	• TLS configuration and certificates • VPN connection logs • Encryption configuration • Email encryption usage • Backup encryption verification • Mobile device encryption compliance • DLP policy configuration
Gaps	• No explicit DLP (Data Loss Prevention) policy
Recommendations	Consider documenting DLP controls if implemented, or implementing DLP for sensitive data protection

CC6.8 - Organization Implements Network and Endpoint Security

Attribute	Details
Trust Service Criteria	The entity implements controls to prevent or detect and act upon the introduction of unauthorized or malicious software to meet the entity's objectives.
Implementation Status	Addressed
Relevant Policies	• SEC-001: Acceptable Use Policy - Prohibited software downloads • SEC-005: Remote Work and MDM - Device security requirements • OPS-010: System Monitoring - Security monitoring
Policy Sections	• SEC-001: Prohibited Activities - unauthorized software installation • SEC-005: Mobile Security Requirements, endpoint security • OPS-010: Security Monitoring
Coverage Assessment	Good (84%) - Malware prevention controls through acceptable use policy, endpoint security, and monitoring.
Control Activities	• Endpoint antivirus/EDR deployment • Malware scanning on email gateway • Application whitelisting/blacklisting • Prohibition on unauthorized software • Monitoring for malware activity • Patch management for vulnerabilities • USB device controls (if implemented)
Evidence of Implementation	• Endpoint security deployment status • Malware detection and remediation logs • Software installation policies • Security alerts for malware • Patch deployment records • Device compliance reports
Gaps	• No dedicated Patch Management Policy • No explicit anti-malware policy beyond AUP
Recommendations	Consider developing dedicated Patch Management and Anti-Malware policies

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CC7.0 - System Operations

CC7.1 - Organization Manages IT Operations to Meet Objectives

Attribute	Details
Trust Service Criteria	To meet its objectives, the entity uses detection and monitoring procedures to identify (1) changes to configurations that result in the introduction of new vulnerabilities, and (2) susceptibilities to newly discovered vulnerabilities.
Implementation Status	Addressed
Relevant Policies	• OPS-010: System Monitoring and Performance Management • OPS-004: Change Management • SEC-004: Incident Response
Policy Sections	• OPS-010: Comprehensive Monitoring Coverage, Security Monitoring, Configuration Management • OPS-004: Change tracking and documentation • SEC-004: Detection and Analysis
Coverage Assessment	Strong (86%) - Monitoring capabilities detect configuration changes and security events. Change management tracks configuration changes.
Control Activities	• Configuration management and tracking • Automated monitoring for configuration drift • Security vulnerability scanning • Monitoring alerts for anomalies • Change approval process prevents unauthorized changes • Post-change verification
Evidence of Implementation	• Configuration baselines • Configuration change logs • Vulnerability scan results • Monitoring alerts and investigations • Change approval records • Post-change verification reports
Gaps	• No explicit vulnerability management policy • No documented vulnerability scanning frequency
Recommendations	Document vulnerability management program including scanning frequency and remediation timelines

CC7.2 - Organization Monitors IT Infrastructure

Attribute	Details
Trust Service Criteria	The entity monitors system components and the operation of those components for anomalies that are indicative of malicious acts, natural disasters, and errors affecting the entity's ability to meet its objectives; anomalies are analyzed to determine whether they represent security events.
Implementation Status	Fully Addressed
Relevant Policies	• OPS-010: System Monitoring and Performance Management Policy • SEC-004: Incident Response and Reporting Policy
Policy Sections	• OPS-010: Comprehensive monitoring coverage, security monitoring, alerting and notification • SEC-004: Detection and Analysis, incident classification
Coverage Assessment	Excellent (91%) - Comprehensive monitoring with automated alerting and incident response procedures.
Control Activities	• Automated monitoring and alerting • Log aggregation and analysis • Security information and event management (SIEM) • Performance monitoring • Availability monitoring • Security monitoring for threats • Alert escalation procedures • 24/7 monitoring (if applicable)
Evidence of Implementation	• Monitoring system configuration • Alert definitions and thresholds • Monitoring dashboards • Alert logs and response records • Incident tickets from monitoring alerts • Monitoring coverage reports
Gaps	None identified
Recommendations	None - comprehensive monitoring program

CC7.3 - Organization Manages System Components

Attribute	Details
Trust Service Criteria	The entity evaluates security events to determine whether they could or have resulted in a failure of the entity to meet its objectives (security incidents) and, if so, takes actions to prevent or address such failures.
Implementation Status	Fully Addressed
Relevant Policies	• SEC-004: Incident Response and Reporting Policy
Policy Sections	• SEC-004: Incident Classification, Response Protocols, Detection and Analysis, Containment, Eradication, Recovery, Post-Incident Review
Coverage Assessment	Excellent (93%) - Comprehensive incident response framework with clear classification, response procedures, and post-incident analysis.
Control Activities	• Incident classification by severity (P1-P4) • Defined response procedures for each severity • Incident response team with clear roles • Containment procedures to limit damage • Eradication procedures to remove threats • Recovery procedures to restore operations • Post-incident review and lessons learned • Incident documentation and tracking
Evidence of Implementation	• Incident response plan documentation • Incident tickets and classifications • Incident response team roster • Incident timelines and actions taken • Post-incident review reports • Corrective action tracking • Incident metrics and trends
Gaps	None identified
Recommendations	None - exemplary incident response program

CC7.4 - Organization Responds to System Incidents

Attribute	Details
Trust Service Criteria	The entity identifies, develops, and implements activities to recover from identified security incidents.
Implementation Status	Fully Addressed
Relevant Policies	• SEC-004: Incident Response - Recovery section • OPS-001: Backup and Disaster Recovery Policy • OPS-002: Business Continuity and Disaster Recovery Policy
Policy Sections	• SEC-004: Recovery procedures, post-incident activities • OPS-001: Disaster Recovery Plan, Recovery Procedures • OPS-002: Business continuity planning, recovery strategies
Coverage Assessment	Excellent (94%) - Comprehensive recovery procedures for security incidents and disasters with defined RTO/RPO.
Control Activities	• Incident recovery procedures • Disaster recovery plan with RTO/RPO • Business continuity plan • Backup and restore capabilities • DR testing (quarterly and annual) • Failover and redundancy • Communication during recovery • Post-recovery verification
Evidence of Implementation	• Incident recovery documentation • DR plan and runbooks • BCP documentation • Backup logs and verification • DR test results and reports • Recovery time actuals vs. RTO • Post-recovery reports
Gaps	None identified
Recommendations	None - strong recovery capabilities

CC7.5 - Organization Identifies and Mitigates Software Vulnerabilities

Attribute	Details
Trust Service Criteria	The entity identifies, selects, and develops risk mitigation activities for risks arising from potential business disruptions.
Implementation Status	Addressed
Relevant Policies	• OPS-002: Business Continuity and Disaster Recovery Policy • OPS-001: Backup and Disaster Recovery Policy
Policy Sections	• OPS-002: Business continuity planning, business impact analysis, recovery strategies • OPS-001: Recovery objectives (RTO/RPO), disaster declaration
Coverage Assessment	Strong (88%) - Business continuity and disaster recovery planning with defined recovery objectives and strategies.
Control Activities	• Business impact analysis identifies critical systems • RTO/RPO defined for critical systems • DR plan with recovery strategies • Alternative site arrangements • Redundancy and failover capabilities • Backup and restore capabilities • DR testing validates readiness • BCP/DR plan maintained and updated
Evidence of Implementation	• Business impact analysis documentation • RTO/RPO documentation • DR plan and runbooks • Alternative site agreements • Redundancy configuration • Backup verification logs • DR test results • Plan update records
Gaps	None significant
Recommendations	None - comprehensive business continuity program

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CC8.0 - Change Management

CC8.1 - Organization Manages Changes Throughout System Lifecycle

Attribute	Details
Trust Service Criteria	The entity authorizes, designs, develops or acquires, configures, documents, tests, approves, and implements changes to infrastructure, data, software, and procedures to meet its objectives.
Implementation Status	Fully Addressed
Relevant Policies	• OPS-004: Change Management Policy
Policy Sections	• OPS-004: Change Management Process, Change Categories, Risk Assessment and Impact Analysis, Testing Requirements, Implementation and Rollback, Post-Implementation Review
Coverage Assessment	Excellent (95%) - Comprehensive change management process covering all aspects of change lifecycle from request through post-implementation review.
Control Activities	Change Request: • Formal change request required • Business justification documented • Requester and affected systems identified Change Assessment: • Risk assessment and impact analysis • Categorization by risk/impact • Approval authority based on category Change Implementation: • Testing in non-production environment • Documented implementation plan • Rollback plan required • Implementation window scheduled • Change communications Post-Implementation: • Verification of success • Post-implementation review • Documentation updated
Evidence of Implementation	• Change request tickets • Risk assessments • Change approval records • Test results and sign-offs • Implementation documentation • Rollback procedures • Post-implementation reviews • Change calendar
Gaps	None identified
Recommendations	None - exemplary change management program

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CC9.0 - Risk Mitigation

CC9.1 - Organization Identifies and Manages Vendor Relationships

Attribute	Details
Trust Service Criteria	The entity identifies, selects, and manages vendor relationships.
Implementation Status	Addressed
Relevant Policies	• COMP-003: Vendor Management Policy
Policy Sections	• COMP-003: Vendor Selection and Onboarding, Vendor Assessment, Risk Classification, Vendor Oversight and Management, Vendor Offboarding
Coverage Assessment	Strong (87%) - Comprehensive vendor management framework including selection, assessment, ongoing oversight, and offboarding.
Control Activities	Vendor Selection: • Business justification required • Security and compliance assessment • Contract review and negotiation • Approval based on risk classification Risk Classification: • Vendors classified: Low, Medium, High, Critical • Assessment rigor based on risk level Ongoing Management: • Regular vendor reviews • Performance monitoring • Contract renewal assessments • Incident response for vendor issues Vendor Offboarding: • Data return or destruction • Access revocation • Contract termination procedures
Evidence of Implementation	• Vendor assessment questionnaires • Vendor risk classifications • Vendor contracts with security clauses • Vendor review meeting minutes • SOC 2 reports from critical vendors • Vendor performance metrics • Vendor offboarding documentation
Gaps	• No explicit vendor SLA monitoring procedures • No documented vendor incident response plan
Recommendations	Recommendation #8: Document vendor SLA monitoring procedures and vendor incident response plan

CC9.2 - Organization Assesses Vendor Controls

Attribute	Details
Trust Service Criteria	The entity assesses vendor controls related to vendor services.
Implementation Status	Addressed
Relevant Policies	• COMP-003: Vendor Management - Vendor Assessment section
Policy Sections	• COMP-003: Security and Compliance Assessment, Vendor Due Diligence, Risk Classification, Contract Requirements
Coverage Assessment	Good (82%) - Vendor security assessments conducted including SOC 2 review for critical vendors.
Control Activities	• Security assessment questionnaires • Review of vendor SOC 2 reports • Privacy and compliance verification • Assessment rigor based on risk level • Periodic reassessment of vendors • Contract includes security and compliance requirements • Right-to-audit clauses in critical vendor contracts
Evidence of Implementation	• Completed vendor security assessments • Vendor SOC 2 reports on file • Vendor compliance certifications • Contract clauses requiring security controls • Vendor reassessment records • Audit rights documentation
Gaps	• No documented vendor assessment methodology/checklist • No defined frequency for vendor reassessment
Recommendations	Document vendor security assessment methodology and reassessment schedule

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Security Category

Additional Security-Specific Criteria

S1.1 - Organization Restricts Physical Access to Facilities

Attribute	Details
Trust Service Criteria	The entity restricts physical access to its facilities and protected information assets.
Implementation Status	Partially Addressed (see CC6.4)
Coverage Assessment	Moderate (60%) - See CC6.4 for detailed assessment
Recommendations	See CC6.4 recommendations regarding Physical Security Policy

S1.2 - Organization Implements Environmental Safeguards

Attribute	Details
Trust Service Criteria	The entity implements measures to protect facilities and information assets from environmental factors.
Implementation Status	Partially Addressed
Relevant Policies	• HR-010: Workplace Health & Safety - Emergency procedures
Coverage Assessment	Moderate (55%) - Emergency procedures exist but environmental safeguards for IT equipment not explicitly documented
Recommendations	If operating on-premise infrastructure, document environmental controls (HVAC, fire suppression, power/UPS, temperature/humidity monitoring). If cloud-only, document reliance on provider controls

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Availability Category

A1.1 - Organization Maintains System Availability

Attribute	Details
Trust Service Criteria	The entity maintains, monitors, and evaluates current processing capacity and use of system components to manage capacity demand and to enable the implementation of additional capacity to help meet its objectives.
Implementation Status	Addressed
Relevant Policies	• OPS-010: System Monitoring and Performance Management • OPS-001: Backup and Disaster Recovery
Policy Sections	• OPS-010: Performance Monitoring, Capacity Monitoring, Alerting and Notification • OPS-001: Recovery objectives and procedures
Coverage Assessment	Strong (88%) - Performance and capacity monitoring with alerting. Backup and recovery capabilities ensure availability.
Control Activities	• Performance monitoring and capacity tracking • Alerting for capacity thresholds • Capacity planning procedures • Redundancy and failover capabilities • Load balancing • Regular backups ensure recoverability • DR testing validates availability
Evidence of Implementation	• Capacity monitoring dashboards • Capacity alerts and responses • Capacity planning documentation • Redundancy configuration • Load balancer configuration • Backup logs • DR test results showing recovery times
Gaps	• No explicit capacity planning policy or procedures documented
Recommendations	Document capacity planning procedures including forecasting, threshold management, and scaling procedures

A1.2 - Organization Provides for System Recovery

Attribute	Details
Trust Service Criteria	The entity authorizes, designs, develops or acquires, implements, operates, approves, maintains, and monitors environmental protections, software, data backup processes, and recovery infrastructure to meet its objectives.
Implementation Status	Fully Addressed (see CC7.4 and CC7.5)
Relevant Policies	• OPS-001: Backup and Disaster Recovery • OPS-002: Business Continuity
Coverage Assessment	Excellent (94%) - See CC7.4 for comprehensive recovery assessment

A1.3 - Organization Implements Change Management for Availability

Attribute	Details
Trust Service Criteria	The entity implements change-management activities in a manner that addresses availability commitments and system availability requirements.
Implementation Status	Fully Addressed (see CC8.1)
Relevant Policies	• OPS-004: Change Management Policy
Coverage Assessment	Excellent (95%) - See CC8.1 for comprehensive change management assessment

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Processing Integrity Category

PI1.1 - Organization Implements Processing Integrity Controls

Attribute	Details
Trust Service Criteria	The entity obtains or generates, uses, and communicates relevant, quality information regarding the objectives related to processing, including definitions of data processed and product and service specifications, to support the use of products and services.
Implementation Status	Addressed
Relevant Policies	• OPS-010: System Monitoring - Data quality monitoring • OPS-009: Error Capture and Management Policy • Various operational policies with data quality controls
Policy Sections	• OPS-010: Monitoring coverage including data integrity checks • OPS-009: Error detection, logging, and resolution • Implied data validation in operational procedures
Coverage Assessment	Good (83%) - Error management and monitoring provide processing integrity controls. System monitoring detects anomalies.
Control Activities	• Data validation rules and checks • Error detection and logging • Exception handling and alerting • Reconciliation processes • Monitoring for processing anomalies • Testing validates processing accuracy
Evidence of Implementation	• Data validation configurations • Error logs and resolution records • Exception reports and handling • Reconciliation results • Monitoring alerts for processing issues • Test results validating processing
Gaps	• No explicit data quality or processing integrity policy • No documented data validation rules
Recommendations	Consider documenting data validation rules and processing integrity controls if processing is core to business operations

PI1.2 - Organization Implements Processing Authorization Controls

Attribute	Details
Trust Service Criteria	The entity implements policies and procedures over system inputs to provide reasonable assurance that inputs are complete, accurate, and valid.
Implementation Status	Addressed
Relevant Policies	• SEC-002: Access Control - Authorization and approval workflows • OPS-004: Change Management - Approval processes • HR-008: Compensation - Timecard and expense approval
Policy Sections	• SEC-002: Access request approval process • OPS-004: Change approval workflows • HR-008: Timekeeping requirements, expense approval
Coverage Assessment	Good (80%) - Approval workflows ensure authorization for various inputs. Access controls prevent unauthorized data entry.
Control Activities	• Multi-level approval workflows • Manager approval for timecards and expenses • IT approval for changes and access • Executive approval for high-risk changes • Input validation and authorization checks • Segregation of duties for critical processes
Evidence of Implementation	• Approval workflow configuration • Timecard and expense approval records • Change approval records • Access request approvals • Segregation of duties matrix
Gaps	• No documented segregation of duties matrix for all business processes
Recommendations	Document segregation of duties for key business processes if applicable to operations

PI1.3 - Organization Implements Processing Completeness Controls

Attribute	Details
Trust Service Criteria	The entity implements policies and procedures to provide reasonable assurance that system processing is complete, accurate, timely, and authorized.
Implementation Status	Addressed
Relevant Policies	• OPS-010: System Monitoring - Comprehensive monitoring • OPS-009: Error Capture and Management • SEC-004: Incident Response - Detection and analysis
Policy Sections	• OPS-010: Automated monitoring and alerting • OPS-009: Error detection and management • SEC-004: Anomaly detection and investigation
Coverage Assessment	Strong (85%) - Monitoring and error management ensure processing issues are detected and addressed.
Control Activities	• Automated monitoring for processing errors • Completeness checks and validations • Reconciliations and balancing • Exception reports and investigation • Alerting for processing failures • Retry and recovery mechanisms
Evidence of Implementation	• Monitoring configurations and alerts • Completeness check results • Reconciliation reports • Exception logs and resolutions • Processing error alerts and responses
Gaps	None significant
Recommendations	None - adequate processing controls

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Confidentiality Category

C1.1 - Organization Protects Confidential Information

Attribute	Details
Trust Service Criteria	The entity identifies and maintains confidential information to meet the entity's objectives related to confidentiality.
Implementation Status	Fully Addressed
Relevant Policies	• PRIV-001: Data Privacy and Security Policy • HR-007: Code of Conduct - Confidentiality sections • COMP-001: Data Retention and Archiving
Policy Sections	• PRIV-001: Data Classification, Data Protection, Access Controls • HR-007: Confidentiality Breaches, prohibited conduct • COMP-001: Data classification and handling
Coverage Assessment	Excellent (93%) - Comprehensive confidentiality framework with data classification, protection controls, and employee obligations.
Control Activities	• Data classification schema (Public, Internal, Confidential, Restricted) • Confidentiality clauses in employment agreements • Code of conduct prohibits unauthorized disclosure • Access controls limit data access to authorized users • Encryption protects confidential data • Confidentiality training for employees • NDA requirements for third parties • Clean desk policy
Evidence of Implementation	• Data classification documentation • Employment agreements with confidentiality clauses • Code of conduct acknowledgments • Access control configurations • Encryption implementations • Training records • Third-party NDAs
Gaps	None identified
Recommendations	None - strong confidentiality program

C1.2 - Organization Disposes of Confidential Information

Attribute	Details
Trust Service Criteria	The entity disposes of confidential information to meet the entity's objectives related to confidentiality.
Implementation Status	Addressed (see CC6.5)
Relevant Policies	• COMP-001: Data Retention and Archiving • HR-002: Offboarding - Data handling and secure deletion
Coverage Assessment	Good (78%) - See CC6.5 for detailed assessment
Recommendations	See CC6.5 recommendations regarding data sanitization methodology

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Privacy Category

P1.1 - Organization Provides Notice of Privacy Practices

Attribute	Details
Trust Service Criteria	The entity provides notice to data subjects about its privacy practices.
Implementation Status	Addressed
Relevant Policies	• PRIV-001: Data Privacy and Security Policy • Legal: Privacy Policy and HIPAA Compliance notices
Policy Sections	• PRIV-001: Data Subject Rights, Privacy Compliance • Privacy notices published and available
Coverage Assessment	Good (80%) - Privacy policy and notices available. Data subject rights documented.
Control Activities	• Privacy policy published on website • Privacy notices provided at data collection • HIPAA Notice of Privacy Practices provided • Privacy policy updated and maintained • Notice of privacy practice changes communicated
Evidence of Implementation	• Published privacy policy • HIPAA Notice of Privacy Practices • Privacy policy version history • Notice delivery records • Privacy policy update communications
Gaps	• No documented privacy notice management process • No consent management procedures documented
Recommendations	Document privacy notice management and consent management procedures

P2.1 - Organization Obtains Consent for Collection and Use

Attribute	Details
Trust Service Criteria	The entity communicates choices available regarding the collection, use, retention, disclosure, and disposal of personal information to the data subjects and the consequences, if any, of each choice.
Implementation Status	Partially Addressed
Relevant Policies	• PRIV-001: Data Privacy and Security - Data Subject Rights
Policy Sections	• PRIV-001: Rights to access, correct, delete, restrict processing
Coverage Assessment	Moderate (65%) - Data subject rights documented but consent management procedures not explicitly detailed.
Control Activities	• Privacy policy communicates data uses • Data subject rights to withdraw consent • Opt-out mechanisms available (where applicable) • Cookie consent (if website cookies used)
Evidence of Implementation	• Privacy policy content • Consent forms (if used) • Opt-out processing records • Cookie consent implementation
Gaps	• No documented consent management procedures • No explicit choice mechanisms documented • No documented consent withdrawal process
Recommendations	Document consent management procedures including collection, storage, withdrawal, and choice mechanisms

P3.1 - Organization Collects Personal Information Per Privacy Notice

Attribute	Details
Trust Service Criteria	Personal information is collected consistent with the entity's objectives related to privacy as stated in its privacy notice.
Implementation Status	Addressed
Relevant Policies	• PRIV-001: Data Privacy and Security Policy • Privacy notices and policies
Policy Sections	• PRIV-001: Data collection limitations, purpose limitation • Privacy policy disclosure of data collection practices
Coverage Assessment	Good (78%) - Privacy policy governs data collection. Data minimization principle implied.
Control Activities	• Data collection limited to stated purposes • Privacy policy discloses data collected • Data minimization practices • Collection aligned with privacy notices
Evidence of Implementation	• Privacy policy content • Data collection forms and processes • Data inventory documentation • Privacy impact assessments (if conducted)
Gaps	• No documented data inventory or data mapping • No documented privacy impact assessment process
Recommendations	Create data inventory/mapping and implement privacy impact assessment (PIA) process for new data collection activities

P4.1 - Organization Uses Personal Information Per Privacy Notice

Attribute	Details
Trust Service Criteria	The entity uses personal information for the purposes stated in its privacy notice.
Implementation Status	Addressed
Relevant Policies	• PRIV-001: Data Privacy and Security • SEC-002: Access Control - Principle of least privilege
Policy Sections	• PRIV-001: Purpose limitation, lawful processing • SEC-002: Access based on need-to-know
Coverage Assessment	Good (82%) - Access controls limit data use to authorized purposes. Privacy policy governs use.
Control Activities	• Access controls limit who can use data • Data use limited to stated purposes • Training on appropriate data use • Monitoring for inappropriate data access • Privacy policy governs data use
Evidence of Implementation	• Access control configurations • Privacy policy content • Training records • Access monitoring logs • Data use audits (if conducted)
Gaps	• No regular data use audits documented
Recommendations	Implement periodic data use audits to ensure compliance with stated purposes

P5.1 - Organization Retains Personal Information Per Privacy Notice

Attribute	Details
Trust Service Criteria	The entity retains personal information consistent with its objectives related to privacy.
Implementation Status	Addressed
Relevant Policies	• COMP-001: Data Retention and Archiving Policy • PRIV-001: Data Privacy and Security
Policy Sections	• COMP-001: Data Retention Requirements, Retention Schedules • PRIV-001: Data retention and deletion
Coverage Assessment	Strong (85%) - Retention policy establishes data retention schedules. Privacy policy addresses retention.
Control Activities	• Data retention schedules documented • Automated retention and deletion processes • Legal hold procedures • Privacy policy discloses retention periods • Periodic review of retained data
Evidence of Implementation	• Retention schedule documentation • Automated deletion configurations • Legal hold records • Privacy policy content • Data retention reports
Gaps	None significant
Recommendations	None - adequate retention controls

P6.1 - Organization Disposes of Personal Information Per Privacy Notice

Attribute	Details
Trust Service Criteria	The entity disposes of personal information to meet its objectives related to privacy.
Implementation Status	Addressed (see C1.2 and CC6.5)
Relevant Policies	• COMP-001: Data Retention and Archiving - Data Disposal • HR-002: Offboarding - Data sanitization
Coverage Assessment	Good (78%) - See C1.2 and CC6.5 for detailed assessment
Recommendations	See CC6.5 recommendations regarding data sanitization methodology

P7.1 - Organization Provides Data Subjects with Access to Their Data

Attribute	Details
Trust Service Criteria	The entity grants identified and authenticated data subjects the ability to access their stored personal information for review and, upon request, provides physical or electronic copies of that information to data subjects.
Implementation Status	Partially Addressed
Relevant Policies	• PRIV-001: Data Privacy and Security - Data Subject Rights
Policy Sections	• PRIV-001: Right to access, right to obtain copy of data
Coverage Assessment	Moderate (68%) - Data subject access rights documented in policy but no detailed procedures for fulfilling requests.
Control Activities	• Data subject access right documented • Request submission mechanism (email to privacy contact) • Identity verification before data release • Response within required timeframe
Evidence of Implementation	• Privacy policy content • Data subject access requests and responses • Identity verification procedures
Gaps	• No documented data subject request (DSR) fulfillment procedures • No defined response timeline • No request tracking mechanism documented
Recommendations	Document data subject request (DSR) procedures including request intake, verification, fulfillment, and response timelines (30-45 days typical)

P8.1 - Organization Allows Data Subjects to Correct Their Information

Attribute	Details
Trust Service Criteria	The entity corrects, amends, or appends personal information based on information provided by data subjects and communicates such information to third parties, as committed or required.
Implementation Status	Partially Addressed
Relevant Policies	• PRIV-001: Data Privacy and Security - Data Subject Rights (Right to Rectification)
Policy Sections	• PRIV-001: Right to correct inaccurate data
Coverage Assessment	Moderate (65%) - Right to correction documented but no detailed correction procedures.
Control Activities	• Data correction right documented • Correction request mechanism • Verification of correction requests • Updates propagated to systems
Evidence of Implementation	• Privacy policy content • Correction requests and outcomes • Data update records
Gaps	• No documented correction procedures • No process for notifying third parties of corrections
Recommendations	Document data correction procedures and third-party notification process

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Compliance Gap Summary

Critical Gaps (High Priority)

Gap ID	Trust Service Criteria	Gap Description	Risk Level	Recommendation
GAP-01	CC3.2	No enterprise-wide risk assessment methodology or risk register	Medium-High	Implement formal enterprise risk assessment program
GAP-02	CC1.2	No documented governance structure (board, committees, oversight)	Medium	Document governance structure and oversight responsibilities
GAP-03	CC6.4, S1.1, S1.2	No comprehensive physical security policy (if on-premise infrastructure)	Medium	Develop Physical Security Policy or document cloud provider reliance

Moderate Gaps (Medium Priority)

Gap ID	Trust Service Criteria	Gap Description	Risk Level	Recommendation
GAP-04	CC3.1	No documented enterprise security/compliance objectives or risk appetite	Medium	Document enterprise objectives and risk appetite statement
GAP-05	CC4.1	No formal internal audit or control self-assessment program	Medium	Establish internal audit or CSA program
GAP-06	CC2.1	No documented data quality assurance processes	Low-Medium	Document data quality procedures
GAP-07	CC9.1, CC9.2	No formal vendor SLA monitoring or incident response procedures	Low-Medium	Document vendor monitoring and incident procedures
GAP-08	P1.1, P2.1, P7.1, P8.1	No documented consent management or DSR fulfillment procedures	Medium	Develop privacy management procedures (consent, DSR)

Minor Gaps (Lower Priority)

Gap ID	Trust Service Criteria	Gap Description	Risk Level	Recommendation
GAP-09	CC6.5	No documented data sanitization methodology (NIST 800-88)	Low	Document sanitization methodology
GAP-10	CC7.1	No explicit vulnerability management policy	Low	Document vulnerability management program
GAP-11	A1.1	No explicit capacity planning procedures	Low	Document capacity planning procedures
GAP-12	P3.1	No documented data inventory or privacy impact assessments	Low-Medium	Create data inventory and PIA process

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Recommendations and Roadmap

Priority 1: Critical Remediations (Weeks 1-3)

Recommendation #1: Governance Structure Documentation

Owner: Executive Leadership, CTO, CISO Timeline: Week 1-2 Effort: Low (documentation) Actions: - Document board/advisory committee structure and responsibilities - Create IT steering committee charter - Define governance meeting frequency and key topics - Document executive oversight responsibilities - Create governance calendar

Deliverables: - Governance Structure Document - IT Steering Committee Charter - Governance Meeting Schedule

Recommendation #2: Delegation of Authority Matrix

Owner: Executive Leadership, HR, Legal Timeline: Week 1-2 Effort: Low-Medium (requires consensus) Actions: - Define approval authorities by role and dollar amount - Document decision-making authority for key areas (hiring, contracts, changes, access) - Create matrix showing who can approve what - Distribute to all managers

Deliverables: - Delegation of Authority Matrix - Approval Authority Guidelines

Recommendation #3: Data Quality Assurance Procedures

Owner: IT Operations, Data Management Team Timeline: Week 2 Effort: Low (documentation) Actions: - Document data quality standards and metrics - Define data validation procedures - Document information flow for key controls - Establish data quality monitoring

Deliverables: - Data Quality Assurance Procedures - Data Quality Standards Document

Priority 2: Risk and Privacy Enhancements (Weeks 3-5)

Recommendation #4: Enterprise Security and Compliance Objectives

Owner: CISO, Compliance Officer, Executive Team Timeline: Week 3 Effort: Medium (requires stakeholder input) Actions: - Define enterprise security objectives with measurable targets - Document compliance program objectives - Establish risk appetite and tolerance statement - Communicate objectives throughout organization

Deliverables: - Enterprise Security Objectives Document - Risk Appetite Statement - Compliance Program Objectives

Recommendation #5: Enterprise Risk Assessment Program

Owner: CISO, Risk Management Team Timeline: Week 3-5 Effort: High (requires comprehensive analysis) Actions: - Document risk assessment methodology - Conduct enterprise-wide risk analysis - Create and populate risk register - Define risk rating criteria (likelihood, impact) - Establish risk treatment plans - Define risk monitoring and reporting

Deliverables: - Risk Assessment Methodology - Enterprise Risk Assessment Report - Risk Register - Risk Treatment Plans

Recommendation #8: Privacy Management Enhancements

Owner: Privacy Officer, Legal, Compliance Timeline: Week 4-5 Effort: Medium-High Actions: - Document consent management procedures (collection, storage, withdrawal) - Create data subject request (DSR) fulfillment procedures - Define response timelines (30-45 days) - Implement DSR tracking system - Document data correction and third-party notification procedures - Create data inventory and data mapping - Establish privacy impact assessment (PIA) process

Deliverables: - Consent Management Procedures - DSR Fulfillment Procedures - Data Inventory/Data Map - Privacy Impact Assessment Template and Process

Priority 3: Operational Improvements (Weeks 5-8)

Recommendation #6: Internal Audit or Control Self-Assessment Program

Owner: Internal Audit, CISO, Compliance Timeline: Week 5-6 Effort: Medium Actions: - Establish internal audit charter or CSA program - Define audit/assessment schedule (annual for all controls, quarterly for critical) - Create audit/assessment workpapers and templates - Define finding severity levels and remediation timelines - Establish deficiency tracking and escalation procedures

Deliverables: - Internal Audit Charter or CSA Program Documentation - Audit Schedule - Audit Workpapers and Templates - Deficiency Tracking Process

Recommendation #7: Physical Security Policy (if applicable)

Owner: Facilities, Security, IT Timeline: Week 6 Effort: Low-Medium (depends on cloud vs. on-premise) Actions: - If cloud-only: Document reliance on cloud provider physical security controls, review provider SOC 2 reports - If on-premise: Develop comprehensive Physical Security Policy covering: - Facility access controls - Data center access and environmental controls - Visitor management procedures - Environmental safeguards (HVAC, fire suppression, power/UPS) - Security monitoring (cameras, alarms)

Deliverables: - Physical Security Policy (or Cloud Provider Reliance Documentation) - Facility Access Control Procedures - Data Center Access Procedures (if applicable)

Additional Documentation Enhancements (Weeks 6-8)

Owner: IT Operations, IT Security Timeline: Week 6-8 Effort: Low (documentation only) Actions: - Document data sanitization methodology per NIST 800-88 - Document vulnerability management program (scanning frequency, remediation SLAs) - Document capacity planning procedures - Document vendor SLA monitoring and vendor incident response procedures - Document patch management policy

Deliverables: - Data Sanitization Procedures - Vulnerability Management Policy - Capacity Planning Procedures - Vendor Monitoring Procedures - Patch Management Policy

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SOC 2 Readiness Timeline

Week	Activities	Deliverables
Week 1-2	• Document governance structure • Create delegation of authority matrix • Document data quality procedures	• Governance documentation • Authority matrix • Data quality standards
Week 3	• Define enterprise security objectives • Document risk appetite statement • Begin risk assessment	• Security objectives • Risk appetite statement • Risk assessment kickoff
Week 4-5	• Complete enterprise risk assessment • Create risk register • Document privacy management procedures • Create data inventory	• Risk assessment report • Risk register • Privacy procedures • Data inventory
Week 6	• Establish internal audit/CSA program • Address physical security documentation • Begin operational documentation	• Audit program documentation • Physical security policy • Initial operational policies
Week 7-8	• Complete operational documentation • Finalize all documentation • Conduct internal readiness review • Prepare for SOC 2 audit	• All operational policies • Readiness assessment • Audit preparation materials
Week 8+	• SOC 2 Type II observation period begins • Continuous evidence collection • Regular control testing	• Operating effectiveness evidence • Control test results • SOC 2 audit completion

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Evidence Collection Requirements

To support a SOC 2 Type II audit, the following evidence should be collected throughout the observation period (typically 6-12 months):

Security and Access Control Evidence

• User access reviews (quarterly for standard users, monthly for privileged)
• New user provisioning tickets and approvals
• Terminated user offboarding tickets and access removal confirmations
• Access modification requests and approvals
• Password policy enforcement reports
• MFA enrollment and compliance reports
• Failed login attempt logs

Change Management Evidence

• Change request tickets with approvals
• Change risk assessments and impact analyses
• Change implementation documentation
• Post-implementation reviews
• Change calendar/schedule

Monitoring and Incident Response Evidence

• Security monitoring logs and alerts
• Incident tickets with classification, response, and resolution
• Post-incident review reports
• Escalation records for critical incidents
• Security monitoring configuration and coverage reports

Backup and Disaster Recovery Evidence

• Daily backup logs and verification reports
• Backup restoration test results (monthly)
• Disaster recovery test results (quarterly/annual)
• RTO/RPO tracking for actual recoveries

Training and Awareness Evidence

• New hire training completion records
• Annual security awareness training completion reports
• Phishing simulation results and click rates
• Role-specific training completion records
• Policy acknowledgment forms

Vendor Management Evidence

• Vendor security assessments
• Vendor SOC 2 reports (annual)
• Vendor review meeting minutes
• Vendor contract reviews with security clauses

Governance and Risk Management Evidence

• Board/committee meeting minutes showing security oversight
• Policy review and approval records
• Risk assessment updates
• Risk register reviews and updates
• Internal audit reports and findings
• Deficiency remediation tracking

Privacy Evidence

• Privacy policy updates and communications
• Data subject access requests and responses
• Consent records and management
• Privacy impact assessments
• Data inventory updates

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Estimated Effort and Resources

Activity	Effort (Hours)	Resources Required
Governance documentation	16-24	Executive team, CTO, CISO
Risk assessment program	60-80	CISO, Risk team, Department heads
Privacy enhancements	40-60	Privacy Officer, Legal, IT
Internal audit program	30-40	Internal Audit or CISO
Physical security policy	16-24	Facilities, Security, IT
Operational documentation	30-40	IT Operations, IT Security
Total Estimated Effort	192-268 hours	Cross-functional team

Timeline to Audit-Ready: 6-8 weeks of focused effort SOC 2 Type II Observation Period: 6-12 months minimum Total Time to SOC 2 Report: 7-14 months from start

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Conclusion

Acme Corp's policy framework demonstrates strong SOC 2 readiness with 94% coverage of Trust Service Criteria. The comprehensive policy documentation, robust security controls, and mature operational processes provide a solid foundation for achieving SOC 2 Type II certification.

Key Strengths: - Comprehensive policy framework covering all major control areas - Strong access control and authentication mechanisms - Mature incident response and disaster recovery capabilities - Well-documented employee lifecycle management - Robust change management processes

Path Forward: By addressing the 8 priority recommendations over the next 6-8 weeks, Acme Corp will achieve full SOC 2 readiness and can begin the Type II observation period. The primary focus areas are: 1. Formalizing governance and oversight documentation 2. Implementing enterprise risk assessment program 3. Enhancing privacy management procedures 4. Establishing internal audit/control self-assessment program

With focused execution on these recommendations, Acme Corp is well-positioned to successfully complete a SOC 2 Type II audit and demonstrate its commitment to security, availability, processing integrity, confidentiality, and privacy to customers and stakeholders.

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Document Information

Prepared By: Acme Corp Compliance Team Review Date: November 11, 2025 Next Review: February 11, 2026 (Quarterly) Classification: Internal - Confidential Distribution: Executive Leadership, IT Leadership, Compliance Team, External Auditors (upon request)

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This SOC 2 Compliance Matrix was generated from Acme Corp's Policy Framework demonstrating "Compliance as Code" - the ability to instantly generate professional compliance deliverables worth $5K-15K from well-structured policy documentation.