Template draft. Replace everything in [square brackets] with your own decision,
delete what does not describe what you really do, and approve it through your own document control. It is not legal
advice and does not make an organisation compliant or certified.
1. Purpose
This policy reduces the chance and effect of malicious software, including viruses, worms, ransomware, spyware, trojans, rootkits, malicious scripts and malicious documents, reaching the Organisation's systems and information. It combines technical controls, user behaviour and a tested response.
2. Scope
The policy applies to all devices that connect to the Organisation's networks or process its information: servers, workstations, laptops, mobile devices, virtual machines, containers, cloud workloads and appliances, whether owned by the Organisation or by the user under an approved arrangement.
- In scope: employees, contractors, visitors with network access and suppliers who connect to Organisation systems.
- Out of scope: operational technology and appliances that cannot run protection software; these are handled by network isolation and recorded as exceptions with compensating controls.
3. Terms and Definitions
| Term | Meaning |
|---|
| Malware | Software designed to damage, disrupt, steal from or take control of a system or data. |
| Endpoint detection and response (EDR) | Endpoint tooling that detects suspicious behaviour, records activity and allows remote containment. |
| Signature-based detection | Matching files against patterns of known malware. |
| Behavioural detection | Recognising malware from what it does, not only what it looks like. |
| Quarantine | Isolating a file or device so it cannot spread or run. |
| Application allow-listing | Permitting only approved software to run. |
4. Roles and Responsibilities
| Role | Responsibilities |
|---|
| Head of IT Security (document owner) | Owns this policy, selects protection tooling, approves exceptions, reviews malware trends. |
| Security operations analyst | Monitors detections, contains infected devices, investigates and reports. |
| Endpoint administrator | Deploys and updates tools, monitors coverage and health, builds images with protection active. |
| Service desk | Receives reports from users, isolates reported devices as directed and logs incidents. |
| Users | Do not disable protection, do not install unapproved software, report suspicious email, files and behaviour at once. |
| System owner | Ensures protection runs on their systems and approves exceptions only through the Head of IT Security. |
| Activity | Responsible | Accountable | Consulted | Informed |
|---|
| Deploy and maintain protection tooling | Endpoint administrator | Head of IT Security | System owners | Service desk |
| Monitor detections and contain threats | Security operations analyst | Head of IT Security | Endpoint administrator | System owner |
| Report suspected malware | User | Line manager | Service desk | Security operations |
| Reimage a compromised device | Endpoint administrator | Head of IT Operations | Security operations | User |
| Run awareness on phishing and malware | Information security manager | Head of IT Security | HR | All staff |
| Review exceptions and allow-lists | Information security manager | Head of IT Security | System owners | Internal audit |
5. Policy Statements
5.1 Protection against malware
- Every in-scope device must run current, centrally managed malware protection before it joins the network. Devices without it must be refused network access or placed in a quarantine network.
- Protection must include real-time scanning, behavioural detection, ransomware protection and, for Tier 1 servers and all laptops, EDR with central logging.
- Users must not disable, uninstall or alter protection. Only the endpoint administrator may change settings, and tamper protection must be turned on.
- Only software from the approved software list may be installed. Administrator rights on endpoints are removed from ordinary users; software that is not on the list needs approval by the information security manager.
- Software and files downloaded from external sources must be scanned before use. Executable and script content in email attachments from outside the Organisation must be blocked or sandboxed.
- Removable media is blocked by default. Where allowed, it must be scanned at every connection and encrypted when it holds Confidential data.
- Web filtering must block categories known to deliver malware, newly registered domains and sites with poor reputation, as the Acceptable Usage Policy describes.
- Macros in documents from outside the Organisation are disabled by default; signed macros from approved publishers may run.
| Control layer | Control | Where it applies |
|---|
| Email | Scanning, attachment sandboxing, link rewriting and checks on sender authenticity | Email gateway and mailboxes |
| Web | Category and reputation filtering, download scanning, TLS inspection where approved | Proxy, DNS filtering, remote users |
| Endpoint | Anti-malware, EDR, application control, device encryption, host firewall | Laptops, desktops, servers |
| Network | Segmentation, egress filtering, intrusion detection | Network boundaries and internal zones |
| Identity | Multi-factor authentication, least privilege, blocking of legacy protocols | All accounts |
| Data | Immutable backups, tested restore | Tier 1 and Tier 2 systems |
5.2 Malware protection software
| Requirement | Default value |
|---|
| Signature and engine update frequency | At least [every 4 hours], and immediately on release of urgent definitions |
| Full scan of workstations | [Weekly]; quick scan [daily]; scan of any connected media at insertion |
| Full scan of servers | [Weekly], scheduled outside peak time; real-time scanning with approved exclusions |
| Agent health check | Device flagged if not seen by management console for [24 hours] or definitions older than [3 days] |
| Coverage target | [99%] of in-scope devices with a healthy agent |
| Central reporting | All detections sent to the central console and the log platform in near real time |
- The tool must be supported by its supplier and updated with new versions within [30 days] of release. End-of-life tools must be replaced under the Change Management Policy and Procedure.
- Scanning exclusions must be requested through a ticket, justified, approved by the information security manager, recorded in the exclusion register and reviewed [every 6 months].
- The management console must be protected with multi-factor authentication, and the people who can uninstall agents or change policy are named in the access review.
- Operating systems and applications must be patched under the Patch Management Policy, since malware often uses known vulnerabilities.
5.3 User awareness and reporting
- All staff must complete awareness training on phishing, malicious attachments, fake updates and removable media at induction and at least every [12 months].
- Simulated phishing exercises are run at least [quarterly]. Results are used for training and not for punishment unless a person repeatedly ignores training or conceals an incident.
- Users must report suspected malware or suspicious messages at once through the report button or the service desk, and must not try to clean a device themselves.
5.4 Response to a malware event
- Detect and reportA detection, user report or alert reaches security operations. Target: triage within [15 minutes] for EDR high-severity alerts.
- ContainIsolate the device from the network using EDR or the switch port, disable affected accounts, block malicious addresses and hashes. Target: within [30 minutes] of confirmation.
- AssessDetermine malware type, entry route, systems and data affected, and whether other devices are involved. Decide if the event is an incident, and follow the Information Security Incident Management Policy.
- Eradicate and recoverReimage affected devices from a trusted build; restore data from clean backups; reset credentials that may be exposed.
- ReportWhere the event is a reportable cyber incident, report it within [6 hours] of noticing it as required by the CERT-In Directions of 28 April 2022 [confirm the current requirement]. Notify customers and authorities according to the incident procedure.
- LearnRecord cause, timeline and actions; update rules, awareness material and baselines.
Note. Ransomware: do not pay or contact attackers without approval of top management and legal advice. Preserve evidence and affected systems where possible, and recover from isolated backups.
6. Severity Guide
| Severity | Example | Response |
|---|
| Critical | Active ransomware encryption; malware on a Tier 1 server; credential theft tool on a domain controller | Immediate isolation, incident manager called, management informed within [1 hour] |
| High | Malware on several endpoints; successful execution on one endpoint with EDR containment | Isolation and investigation within [4 hours] |
| Medium | Blocked malicious attachment delivered to several users; potentially unwanted software | Remove and check within [1 working day] |
| Low | Single blocked detection with no execution | Log and review in the weekly report |
7. Compliance and Monitoring
- The endpoint administrator reports coverage and health of agents weekly; devices that do not meet the target are fixed or disconnected.
- The information security manager reviews detections, exclusions and user-reported cases monthly, and reports trends to the information security forum each [quarter].
- Detection and response capability is tested at least [once a year] with a safe test file, a simulated phishing campaign and a response exercise.
8. Measures
| Measure | Target |
|---|
| Devices with a healthy agent | [99%] |
| Devices with definitions less than [3 days] old | [99%] |
| Median time from detection to containment | [under 30 minutes] |
| Phishing simulation click rate | [below 5%] |
| Phishing simulation report rate | [above 60%] |
| Staff with current awareness training | [100%] |
9. Records and Evidence
- Agent coverage and health reports, kept [12 months].
- Detection and incident records and containment actions, kept [3 years].
- Exclusion register and approvals, kept while current plus [2 years].
- Awareness completion and simulation results, kept [3 years].
Annexure A: Malware event record
| Field | Entry |
|---|
| Date, time and reporter | |
| Device, user and location | |
| Detection source and malware name | |
| Containment time and action | |
| Systems and data affected | |
| Eradication and recovery | |
| Linked incident number | |
| Lessons learned and actions | |
10. Exception
Exceptions to this document are allowed only where compliance is not practicable and the risk has been assessed. A request must state what is to be excepted, why, the risk it creates, the compensating controls, and an end date no later than [6 months]. It is approved in writing by the document owner and the risk owner, recorded in the exceptions register, and reviewed at the end date. An exception does not change the document.
11. Enforcement
Compliance is monitored through internal audits, management review and routine checks by the document owner. Non-compliance is reported through the incident or non-conformity process and handled under the organisation's disciplinary procedure, and under the terms of any contract for people who are not employees. Serious or repeated non-compliance may lead to loss of access and, where the law is broken, to referral to the authorities.
12. Review
This document is reviewed at least every [12 months], and when there is a significant change to the organisation, its systems, its risks or the law, or after an incident that shows it was not effective. Each review is recorded in the revision history.
ISO/IEC 27001:2022 references
| Reference | Title |
|---|
| A.8.7 | Protection against malware |
| A.8.23 | Web filtering |
| A.8.19 | Installation of software on operational systems |
| A.6.3 | Information security awareness, education and training |
| A.5.25 | Assessment and decision on information security events |
| A.5.26 | Response to information security incidents |