Governance & Compliance Policy Template


Company Name	[Company Name]
Effective Date	[Date]
Version	[Version Number, e.g., 1.0]
Policy Owner	[CISO/IT Director or Chief Compliance Officer]
Document Classification	Confidential / Internal Use Only
Parent Policy	Information Security Policy

Purpose

This policy establishes the framework for information security governance and compliance management at [Company Name]. Its purpose is to ensure that security activities align with business objectives, risks are managed effectively, regulatory and contractual obligations (including PCI DSS 4.0.1) are met, security policies are maintained and enforced, and a culture of security awareness is fostered throughout the organization. This policy provides structure for oversight, accountability, risk management, and continuous improvement of the information security program.

Scope

This policy applies to all aspects of information security governance and compliance activities across [Company Name]. This includes risk management processes, policy lifecycle management, security awareness and training programs, compliance monitoring and reporting (for regulations such as PCI DSS, GDPR, CCPA, etc.), internal and external audits, access reviews, network segmentation validation, and management of compensating controls and risk acceptance. All employees, contractors, consultants, and relevant third parties are expected to understand and adhere to the principles and requirements outlined herein.

Roles and Responsibilities

Role/Group	Key Responsibilities
Board of Directors / Executive Management	Provide ultimate oversight for governance, risk, and compliance; Set the organization's risk appetite; Ensure adequate resources for the security program; Review and approve high-level security strategy and risk acceptance.
CISO / IT Director / Compliance Officer	Own and approve this policy; Develop and manage the overall information security governance framework and compliance program; Report on security posture and compliance status to Executive Management; Oversee risk management activities.
Information Security Team	Implement and manage security controls; Develop security policies and standards; Conduct risk assessments; Monitor compliance; Manage security tools; Support audit activities; Oversee vulnerability management and incident response planning.
Compliance / Internal Audit Team	Independently assess and verify compliance with policies, standards, and regulations (including PCI DSS); Conduct internal audits; Coordinate external audits (e.g., QSA assessments); Report findings to management.
Legal Counsel	Interpret legal and regulatory requirements; Advise on compliance obligations, contracts, and potential liabilities; Assist with policy development and incident response legal aspects.
Risk Management Function	Facilitate the enterprise risk management process, including the identification, assessment, and treatment of information security risks.
Business Unit Leaders / Data Owners	Ensure compliance with security policies within their areas; Participate in risk assessments and access reviews; Define data protection requirements for their assets; Implement corrective actions based on audit findings.
IT Operations / System Administrators	Implement technical controls according to policies and standards; Maintain systems securely; Provide evidence for compliance audits; Participate in risk assessments and remediation activities.
Human Resources (HR)	Integrate security responsibilities into job descriptions; Manage security awareness training logistics; Handle policy violations according to disciplinary procedures.
All Employees & Contractors	Adhere to all company policies and standards; Complete mandatory security awareness training; Report security concerns or incidents promptly.

Policy Requirements

1. Information Security Governance Framework

Establish and maintain a formal information security governance structure with defined roles, responsibilities, and reporting lines, ensuring clear accountability for security across the organization.
Align the information security program with business objectives, legal/regulatory requirements, and the organization's risk appetite.
Implement a cycle of planning, implementing, monitoring, reviewing, and improving information security processes and controls (e.g., based on Plan-Do-Check-Act).

2. Compliance Management

Identify, document, and regularly review all applicable legal, regulatory, and contractual information security requirements (e.g., PCI DSS, GDPR, CCPA, HIPAA, client contracts).
Map existing security controls to specific compliance requirements to identify gaps.
Implement processes and controls necessary to meet identified compliance obligations.
Conduct regular internal assessments and coordinate external audits (e.g., PCI DSS assessment by a QSA) to validate compliance. Maintain records of all compliance activities, findings, and remediation efforts.

3. Risk Management Program (PCI DSS Req 12.2)

Establish and maintain a formal risk management program specifically addressing information security risks, including those related to sensitive data (CHD, PII, IP).
Risk Identification: Identify critical assets, threats (internal/external, malware, human error, etc.), and vulnerabilities (technical, procedural) relevant to the environment.
Risk Analysis: Analyze identified risks based on likelihood and potential impact (confidentiality, integrity, availability, compliance, financial, reputational).
Risk Evaluation & Prioritization: Evaluate analyzed risks against risk acceptance criteria defined by management; prioritize risks for treatment based on their rating.
Risk Treatment: Select and implement appropriate controls (technical, administrative, physical) to mitigate identified risks to an acceptable level.
Risk Monitoring & Review: Continuously monitor the effectiveness of controls and the changing threat landscape. Review risk assessments at least annually or upon significant changes to the environment or threat landscape.
Risk Acceptance Documentation Procedure:
- When a risk cannot be mitigated to an acceptable level due to legitimate business or technical constraints, or when specific policy requirements cannot be met (potentially leading to compensating controls), the residual risk must be formally documented and accepted.
- Risk acceptance documentation must include:
  - Clear identification of the risk or non-compliance issue.
  - Documented business justification for accepting the risk.
  - Detailed analysis of the potential impact and likelihood.
  - Any implemented compensating or mitigating controls.
  - A defined period for the acceptance (not indefinite).
  - Formal approval signature(s) from authorized management personnel with the appropriate level of authority based on the risk level (e.g., CISO for low/medium, Executive Management/Board for high/critical).
- Risk acceptance decisions must be reviewed at least annually or when significant changes occur. Maintain a central register of all accepted risks.

4. Policy and Standard Management

Implement a lifecycle management process for all information security policies, standards, and procedures, including creation, review, approval, publication, communication, and retirement.
Review and update all information security policies and standards at least annually or upon significant changes (e.g., regulatory updates, new technologies, major incidents).
Ensure policies and standards are readily accessible to all relevant personnel.

5. Security Awareness and Training (PCI DSS Req 12.6)

Establish and maintain a formal security awareness program for all personnel (employees, relevant contractors).
Conduct awareness training upon hiring and at least annually thereafter, covering topics such as password security, phishing, social engineering, data handling, incident reporting, acceptable use, and specific responsibilities related to compliance requirements (e.g., PCI DSS).
Provide role-specific security training for personnel with significant security responsibilities (e.g., IT admins, developers, finance staff handling CHD).
Maintain records of training participation and completion.

6. Access Review Procedure (PCI DSS Req 7.1.1, 8)

Implement a formal process for periodically reviewing user access rights to ensure they remain appropriate based on current job roles and adhere to the principle of least privilege.
Scope Identification: Define the systems, applications, and data subject to access reviews, prioritizing high-risk systems and those containing sensitive data (including CDE systems).
Frequency: Conduct access reviews at least quarterly for critical systems and privileged access, and at least semi-annually or annually for other systems, or as dictated by specific regulatory requirements.
Responsibility: User managers and System/Application/Data Owners are responsible for conducting or approving the reviews for their respective reports or resources. IT or Security may facilitate the process and provide necessary reports.
Process:
- Generate accurate reports listing users and their current access permissions for the system/application under review.
- Reviewers compare current access against the user's current job role and documented need-to-know.
- Verify that access levels align with approved roles (Role-Based Access Control) where applicable.
- Identify and flag any inappropriate or excessive access privileges.
Documentation: Document the completion of each review, including the scope, date, reviewer(s), findings, and any required remediation actions. Retain review records for audit purposes.
Remediation: Ensure that any identified inappropriate access is promptly revoked or modified through the standard access management process. Track remediation actions to completion.

7. Network Segmentation Controls / CDE Segmentation Standard (PCI DSS Req 1, 11.3.4)

Requirement: Implement network segmentation to isolate systems storing, processing, or transmitting sensitive data (especially the CDE) from less trusted networks. Segmentation must limit the scope of compliance assessments (e.g., PCI DSS scope) and reduce the potential impact of a security breach.
Implementation: Use a combination of technologies like firewalls, VLANs, Access Control Lists (ACLs), and potentially physical separation to enforce segmentation. Firewalls must be configured between the CDE and all other internal and external network segments.
Control Rules: All traffic allowed between network segments (especially into/out of the CDE) must be based on documented business justification, adhere to the principle of least privilege (deny-by-default), and be restricted to necessary ports/protocols/source/destinations.
Validation: The effectiveness of segmentation controls must be validated at least every six months by qualified personnel (internal or external) who are organizationally independent of the network administration. Validation methods include penetration testing, firewall rule reviews, and network configuration analysis. Validation must confirm that CDE systems cannot be accessed from out-of-scope networks.
Documentation: Maintain up-to-date network diagrams clearly showing all segments, boundaries, connections (including third-party connections), and the location of security controls enforcing segmentation.

8. Data Flow Diagram Procedure (PCI DSS Req 1.2.3)

Requirement: Maintain accurate diagrams and supporting documentation identifying the flow of sensitive data (especially CHD) across the network.
Content: Data flow diagrams must illustrate:
- How sensitive data enters the environment (e.g., payment channels, web forms, file uploads).
- Systems involved in processing, storing, or transmitting the data (including applications, databases, servers).
- Network segments traversed by the data.
- Security controls protecting the data at each stage (e.g., encryption, tokenization, firewalls).
- How data leaves the environment (e.g., transmission to processors, archival, disposal).
Maintenance: Data flow diagrams must be reviewed and updated at least annually or whenever significant changes occur to the environment, data flows, or security controls.
Linkage: Diagrams should correspond with network topology diagrams and asset inventories for consistency.

9. Compensating Controls Plan Procedure (PCI DSS Appendix D)

Applicability: Compensating controls may only be considered when an entity cannot meet a specific PCI DSS requirement explicitly as stated due to legitimate technical or documented business constraints. They cannot be used for requirements explicitly stating they must be met without compensation.
Criteria: To be valid, a compensating control must:
- Meet the intent and rigor of the original requirement.
- Provide a similar level of defense as the original requirement, sufficiently mitigating the risk associated with not meeting the requirement.
- Be "above and beyond" other PCI DSS requirements (i.e., not simply meeting another requirement).
- Be commensurate with the additional risk imposed by not adhering to the original requirement.
Documentation (Compensating Controls Worksheet): If compensating controls are used, they must be thoroughly documented in a worksheet containing:
- Constraints: Explanation of the legitimate technical or business constraints preventing adherence to the original requirement.
- Objective: The objective of the original PCI DSS requirement.
- Identified Risk: The specific risk mitigated by the original requirement that is not being met.
- Definition of Compensating Controls: Detailed description of the compensating controls, including people, processes, and technologies used.
- Validation: Explanation of how the compensating controls meet the objective of the original requirement and provide a similar level of defense. Explanation of how they are "above and beyond" other requirements and commensurate with the additional risk.
- Maintenance: Procedures for maintaining and validating the ongoing effectiveness of the compensating controls.
Validation: Compensating controls must be reviewed and validated by a Qualified Security Assessor (QSA) during a PCI DSS assessment.

Enforcement

Non-compliance with this Governance & Compliance Policy, or any referenced security policies and standards, may result in disciplinary action, up to and including termination of employment or contract, in accordanceance with established HR policies and contractual agreements.
Systematic or significant compliance failures may lead to regulatory penalties, fines, legal action, and reputational damage.
Exceptions to specific policy requirements must follow the formal Risk Acceptance Documentation Procedure (Section 3), requiring documented justification, risk assessment, compensating controls (where applicable), and approval from authorized management.

Revision History

Version	Date	Author	Change Details
1.0	[Date]	[Author Name]	Initial policy release
[Ver #]	[Date]	[Author Name]	[Summary of changes, e.g., Added PCI 4.0.1 references]

Approval

Name	Title	Signature	Date
[Exec Name]	[Executive Title, e.g., CEO or Board Rep]		[Date]
[CISO Name]	[CISO/IT Director Title]		[Date]

Appendix A: Access Review Checklist - Example

Review Period: [e.g., Q3 2025] System/Application: [System Name] Reviewer (Manager/Owner): [Reviewer Name] Date: [Date of Review]

User ID	User Name	Current Role/Title	Access Permissions Granted	Still Required? (Y/N)	Justification if Yes / Action if No (e.g., Revoke)	Notes
jsmith	John Smith	Finance Analyst	Read/Write Finance Data	Y	Required for daily reporting tasks
adavis	Anna Davis	Sales Manager	Read Finance Data	N	Role changed 2 months ago; Revoke Read Access	Ticket #12345 submitted
ext_vendor1	Vendor Support	Admin Access	Y	Current project requires admin until [End Date]	Access limited by time/IP
service_acct1	N/A	Batch Processing	Read/Write Order Data	Y	Required for automated order import	Reviewed service account use
...	...	...	...	...	...

Reviewer Signature: _________________________

Appendix B: Data Flow Diagram - Key Elements

A Data Flow Diagram for sensitive data (e.g., CHD) should clearly show:

Data Entry Points: How does the data enter the environment? (e.g., Web server, POS terminal, file import).
Systems: Which specific servers, applications, databases, and network devices process, store, or transmit the data? (Include system names/IPs where practical).
Storage Locations: Where is the data stored? (e.g., Database server name/IP, file share path, cloud storage bucket). Is it encrypted at rest?
Transmission Paths: How does data move between systems? (Network segments, protocols used - e.g., TLS 1.2+ over internal network, SFTP to third party). Is it encrypted in transit?
Security Controls: Where are firewalls, IDS/IPS, WAFs, encryption points, tokenization systems located relative to the data flow?
Data Exit Points: How does data leave the environment? (e.g., Sent to payment processor, archived to tape, securely deleted).
Environment Boundaries: Clearly demarcate the boundaries of the CDE and other network segments.

Appendix C: Compensating Controls Worksheet - Template (Based on PCI DSS Appendix D)

Section	Details
1. Constraints	Explain the legitimate technical or documented business constraints preventing adherence to the original PCI DSS requirement [Req #].
2. Objective	State the objective of the original PCI DSS requirement [Req #].
3. Identified Risk	Describe the specific risk mitigated by the original PCI DSS requirement that is not being met.
4. Definition of Compensating Controls	Detail the compensating controls implemented, including people, processes, and technologies. Be specific.
5. Validation	- Explain how the compensating controls meet the objective of the original requirement. - Explain how they provide a similar level of defense. - Explain how they are "above and beyond" other PCI DSS requirements. - Explain how they are commensurate with the additional risk.
6. Maintenance	Describe the processes and procedures for maintaining and validating the ongoing effectiveness of the compensating controls.
Approved By (QSA):	[QSA Name/Company & Date]
Approved By ([Company Name]):	[Internal Approver Name/Title & Date]

Appendix D: Risk Acceptance Form - Template

Section	Details
Risk ID:	[Unique Identifier]
Date Identified:	[Date]
Identified By:	[Name/Department]
Risk Description:	Clear description of the risk, vulnerability, or non-compliance issue. Reference relevant asset(s) or policy/requirement number.
Potential Impact:	Describe the potential negative consequences if the risk materializes (e.g., financial loss, data breach, reputational damage, downtime).
Likelihood:	Assess the probability of the risk occurring (e.g., High, Medium, Low).
Risk Rating:	Overall risk score/level based on impact and likelihood (e.g., Critical, High, Medium, Low).
Business Justification for Acceptance:	Explain the legitimate business or technical reasons why the risk cannot be fully mitigated at this time.
Mitigating / Compensating Controls in Place:	Describe any controls currently implemented that partially reduce the risk or its impact.
Residual Risk Level:	The level of risk remaining after existing controls are considered.
Acceptance Period:	Define the duration for which this risk acceptance is valid (e.g., 12 months). Must not be indefinite.
Review Date:	Date by which this acceptance must be reviewed.
Conditions (If any):	Any conditions attached to the acceptance (e.g., enhanced monitoring required).
Approved By:
Name:	[Name of Authorized Manager]
Title:	[Title - Must have appropriate authority for the risk level]
Signature:
Date:	[Date]

Appendix E: PCI DSS 4.0.1 Governance & Compliance Requirements Mapping

PCI DSS Requirement	Relevant Policy Section(s)	Key Controls Covered
Req 1 (Network)	Policy Req 7 (Segmentation), Req 8 (Data Flow)	Network segmentation controls and validation, Data flow diagrams.
Req 7 (Access)	Policy Req 6 (Access Review)	Periodic review of user access rights.
Req 11 (Test)	Policy Req 7 (Segmentation - Validation)	Regular testing of segmentation controls.
Req 12 (Overall)	Entire Policy	Maintain a policy, risk assessment program, formal security awareness, personnel screening, TPSP management, incident response.
12.1	Policy Req 1 (Framework), Req 4 (Policy Mgmt)	Maintain information security policy, reviewed annually, accessible to personnel.
12.2	Policy Req 3 (Risk Management Program)	Formal risk assessment process, performed annually or upon significant change.
12.6	Policy Req 5 (Security Awareness and Training)	Formal security awareness program, annual training, role-specific training acknowledgement.
12.8	(Covered by TPSP Management Policy - Referenced)	Policies and procedures for managing TPSPs.
12.9	(Covered by TPSP Management Policy - Referenced)	Requirements for TPSP agreements and responsibilities.
12.10	(Covered by Incident Response Plan - Referenced)	Incident response plan requirements.
Appendix Appendix D	Policy Req 9 (Compensating Controls)	Formal process and documentation for implementing and validating compensating controls.