MICHAEL E. DEBAKEY VETERANS AFFAIRS MEDICAL CENTER

RESEARCH SERVICE LINE

Houston, TX

SUPPLEMENTAL EMERGENCY RESPONSE PLAN

# **1.** **PURPOSE** {#purpose .unnumbered}

a\. This supplemental publication to Medical Center Policy Memorandum
No. 138EmP-001, *Comprehensive Emergency Management Program,* describes
the Research Service Line's response to facility, community and national
emergencies and disasters, and telecommunications and computer failures.

b\. Emergency management functions and related activities of the
Research Service Line (which is comprised of Clinical Science Research
and Development, Biomedical Laboratory Research and Development, Health
Services Research and Development, Rehabilitation Research and
Development, and Cooperative Studies) are supplemental to those listed
in Medical Center Policy Memorandum No. 138EmP-001 and the Michael E.
DeBakey Houston VA Medical Center Research and Development Safety
Manual, although some may be repeated for emphasis.

**2. [REFERENCES]{.underline}**

a\. VHA Handbook 1200.6, Control of Hazardous Agents in VA Research
Laboratories.

b\. MEDVAMC Medical Center Policy Memorandum No. 138EmP-001,
Comprehensive Emergency Management Program.

3\. [GOALS]{.underline}

a\. To assure that the capability exists to continue essential
operations during the full range of man-made, natural, technological,
and national security emergencies.

b.  To ensure a smooth and effective transition from normal to backup
    operations.

c\. To ensure a smooth and effective transition from backup to normal
operations when the emergency has ended.

4\. [OPERATIONS AND PROCEDURES]{.underline}

Coordination and implementation of operational policies and procedures
for dealing with emergencies and natural disasters are set forth in the
attached Chapters. The Research Service Line will be prepared to provide
assistance, if required, to meet the needs of the MEDVAMC during a
facility, community or national emergency or disaster.

# **5. RESPONSIBILITIES** {#responsibilities .unnumbered}

a\. [Designation of Officials]{.underline}

\(1\) The [Associate Chief of Staff for Research]{.underline} is
responsible for the implementation, management, and evaluation of the
Research Service Line Emergency Response Plan.

\(2\) The [Director of Operations for Research]{.underline} is the
designated Research Emergency Manager who coordinates, oversees, and
maintains all aspects of the emergency preparedness and response
program.

\(3\) The [Director, Houston Center for Quality of Care and Utilization
Studies, a VA Health Services Research and Development Service Center of
Excellence]{.underline} is responsible for that Center in the
activation, response, and resumption of activities consistent with this
Plan.

b.  [All Employees]{.underline}

\(1\) Ensure her/his cascade section contact has an up-to-date work and
home telephone number where s/he can be reached.

\(2\) Know her/his role during an emergency or other disruption of
normal operations.

\(3\) Will not knowingly impede telephonic notification procedures.

# **6. WARNING CONDITIONS** {#warning-conditions .unnumbered}

a\. [Advance Warning.]{.underline} There are certain threats to research
operations which afford advance warning and as such permit the orderly
alert, notification, evacuation, and if necessary, relocation of
employees. Situations that provide such warning indicators may include a
hurricane, an accident with a potential hazardous material (HAZMAT)
release, or the threat of a terrorist incident.

b\. [No Warning during duty hours.]{.underline} Incidents may occur with
no warning during normal office hours, e.g., fire, explosion, bomb
threat, power outage, or the threat of a terrorist incident.

c\. [No Warning during non-duty hours.]{.underline} Warning may not
precede incidents, e.g., earthquake, tornado, arson, or HAZMAT
incidents, or the threat of a terrorist incident.

7\. [MONITORING]{.underline}

a\. [The Cascade System for Emergency Calls]{.underline} (see attached
Emergency Response Plan) will be reviewed and updated quarterly. The
Research Emergency Manager will maintain copies of all component lists.

b\. [Program Evaluation.]{.underline} The emergency response system
requires the designated officials to conduct a program of periodic
testing, to include an annual emergency preparedness and response drill,
and evaluation to assure that the capability exists to continue critical
operations and at the same time ensure response and recovery phases are
fully supported. Evaluation activities include after-action critiques
from exercises or actual events providing the feedback loop to unmet
response issues.

c\. Initial and annual [vulnerability assessments]{.underline} of all
research laboratories by a multidisciplinary team consisting of research
personnel, a representative from the VA Police Service, the MEDVAMC
Safety Office, e.g., Safety Manager, Radiation Safety Officer, shall be
conducted. Vulnerability assessments shall also be conducted after any
incident. These assessments are to identify high-risk areas, sensitive
materials, and physical security issues.

8.  [RESCISSION]{.underline}

RSL Handbook 151.1, *Research Service Line Emergency Management Plan,*
dated April 30, 2002.

9.  [RECERTIFICATION]{.underline}

Research Service Line on or before the last working day of April 2006.

/hhb/

HOLLY H. BIRDSALL, MD, PHD

Associate Chief of Staff/Research

Attachment -- Research Service Line Emergency Response Plan

####### RESEARCH SERVICE LINE {#research-service-line .unnumbered}

EMERGENCY RESPONSE PLAN

Attachment

RESEARCH SERVICE LINE

EMERGENCY RESPONSE PLAN

TABLE OF CONTENTS

## Page {#page .unnumbered}

CHAPTER 1 Emergency Response Guide 1

PART A Biological Spill 1

PART B Chemical Spill 3

PART C Fire 4

PART D Medical Emergency 5

PART E Radiation Spill 5

CHAPTER 2 Disaster Response Guide 7

PART A Community Emergency 7

PART B Civil Defense Disaster 7

PART C Civil Disturbance 7

PART D Bomb Threat 7

PART E Major Power, Utility, or Communication Disruptions 7

PART F Severe Weather Emergency 8

PART G Bioterrorism Readiness 8

CHAPTER 3 Unidentified Odor Policy 9

CHAPTER 4 Emergency Response Guidelines 10

PART A Cascade System for Emergency Calls 10

PART B Evacuation of Personnel 10

PART C Security System 10

CHAPTER 5 Evacuation of Personnel With Disabilities 11

PART A Procedures 11

CHAPTER 6 Vivarium Emergency 13

PART A Animal Emergency 13

PART B Security Breach Procedures 14

CHAPTER 7 Cyber Security 15

PART A Security Measures 15

PART B Cyber Security Incident 17

PART C Computer System Failure 17

APPENDIX A Bomb Threat Telephone Report A1

APPENDIX B Cascade Call Lists B1

CHAPTER 1 [EMERGENCY RESPONSE GUIDE]{.underline}

###  {#section .unnumbered}

### PART A BIOLOGICAL SPILL {#part-a-biological-spill .unnumbered}

\(1\) Call 911

\(a\) Alert people in immediate area of spill to evacuate.

(b) Soak paper towels in disinfectant and place over spill area

(c) WEAR PROTECTION

\(2\) Biological spills outside biological safety cabinets will generate
aerosols that can be dispersed in the air throughout the laboratory.
These spills are very serious if they involve microorganisms that
require Biosafety Level 3 (BSL-3) containment. Reduce the risk of
inhalation exposure by holding breath and leave the laboratory
immediately. The laboratory should not be reentered to decontaminate and
clean up the spill for at least one hour. (During this time, the aerosol
will be removed from the laboratory by the exhaust air ventilation
system.) Wear appropriate protective equipment.

###  (a) Spill Involving a Microorganism Requiring BSL 1 Containment (Work involving agents of no known or of minimal potential hazard to laboratory personnel and the environment) {#a-spill-involving-a-microorganism-requiring-bsl-1-containment-work-involving-agents-of-no-known-or-of-minimal-potential-hazard-to-laboratory-personnel-and-the-environment .unnumbered}

> [1]{.underline} Wear disposable gloves.
>
> [2]{.underline} Soak paper towels in disinfectant and place over spill
> area.

[3]{.underline} Place towels in plastic bag for disposal.

> [4]{.underline} Clean spill area with fresh towels soaked in
> disinfectant.

###  (b) Spill Involving a Microorganism Requiring BSL 2 Containment (Work involving agents of moderate potential hazards to personnel and the environment. Laboratory personnel must have specific training in handling pathogenic agents and access to the laboratory is limited when work is being conducted. Procedures in which infectious aerosols are created are conducted in biological safety cabinets or other physical containment equipment.) {#b-spill-involving-a-microorganism-requiring-bsl-2-containment-work-involving-agents-of-moderate-potential-hazards-to-personnel-and-the-environment.-laboratory-personnel-must-have-specific-training-in-handling-pathogenic-agents-and-access-to-the-laboratory-is-limited-when-work-is-being-conducted.-procedures-in-which-infectious-aerosols-are-created-are-conducted-in-biological-safety-cabinets-or-other-physical-containment-equipment. .unnumbered}

1.  Alert people in immediate area of spill.

2.  Put on protective equipment.

3.  Cover spill with paper towels or other absorbent materials.

4.  Carefully pour a freshly prepared 1 in 2 dilution of household
    bleach around the edge of the spill and then into the spill.

5.  Avoid splashing and allow 20 minutes contact.

6.  Use paper towels to wipe up the spill, working from the edge to
    center.

7.  Clean spill area with fresh towels soaked in disinfectant.

8.  Place towels in a plastic bag and dispose of as infectious waste.

###  (c) Spill Involving a Microorganism Requiring BSL 3 Containment (Work is done with indigenous or exotic agents that may cause serious or potentially lethal disease as a result of exposure by the inhalation route. Laboratory personnel have specific training in handling pathogenic and potentially lethal agents. Procedures are conducted within biological safety cabinets or other physical containment devices or by personnel wearing appropriate personal protective clothing and devices. When existing facilities do not have all the facility safeguards recommended for BSL 3 (e.g., access zone, sealed penetrations, and directional airflow, etc.), acceptable safety may be achieved for routine or repetitive operation (e.g., diagnostic procedures involving the propagation of an agent for identification, typing, and susceptibility testing).) {#c-spill-involving-a-microorganism-requiring-bsl-3-containment-work-is-done-with-indigenous-or-exotic-agents-that-may-cause-serious-or-potentially-lethal-disease-as-a-result-of-exposure-by-the-inhalation-route.-laboratory-personnel-have-specific-training-in-handling-pathogenic-and-potentially-lethal-agents.-procedures-are-conducted-within-biological-safety-cabinets-or-other-physical-containment-devices-or-by-personnel-wearing-appropriate-personal-protective-clothing-and-devices.-when-existing-facilities-do-not-have-all-the-facility-safeguards-recommended-for-bsl-3-e.g.-access-zone-sealed-penetrations-and-directional-airflow-etc.-acceptable-safety-may-be-achieved-for-routine-or-repetitive-operation-e.g.-diagnostic-procedures-involving-the-propagation-of-an-agent-for-identification-typing-and-susceptibility-testing. .unnumbered}

1.  Alert people in immediate area of spill.

2.  Put on protective equipment.

3.  Cover spill with paper towels or other absorbent materials.

4.  Carefully pour a freshly prepared 1 in 2 dilution of household
    bleach around the edge of the spill and then into the spill.

5.  Avoid splashing and allow 20 minutes contact.

6.  Use paper towels to wipe up the spill, working from the edge to
    center.

7.  Clean spill area with fresh towels soaked in disinfectant.

8.  Place towels in a plastic bag and dispose of as infectious waste.

PART B [CHEMICAL SPILL]{.underline}

\(1\) Call 911

\(a\) If spilled material is flammable, turn off ignition and heat
sources.

(b) Alert people in the laboratory to evacuate area.

(c) Use spill kits to confine spill.

The cleanup of a chemical spill can only be done by knowledgeable and
experienced personnel. Spill kits with instructions, absorbents,
reactants, and protective equipment are available in laboratories to
contain many minor spills.

\(2\) In the event of a [major chemical spill]{.underline},

\(a\) Attend to the injured or contaminated persons and remove them from
exposure.

(b) Alert people in the laboratory to evacuate.

(c) If spilled material is flammable, turn off ignition and heat
    sources.

\(d\) Close doors to affected area.

\(e\) Have person knowledgeable of incident and laboratory assist
emergency personnel.

\(3\) In the event of a [minor chemical spill,]{.underline}

\(a\) Avoid breathing vapors from spill.

\(b\) Confine spill to small area.

\(c\) Use appropriate kit to contain, neutralize, and absorb inorganic
acids and bases. (Neutralize acid spills with sodium carbonate
neutralize alkali spills with boric acid.)

\(d\) Attend to injured or contaminated persons and remove them from
exposure.

\(e\) Alert people in the laboratory to evacuate.

\(f\) If spilled material is flammable, turn off ignition and heat
sources.

\(g\) Close doors to affected area.

\(h\) Have person knowledgeable of incident and laboratory assist
emergency personnel.

### PART C FIRE {#part-c-fire .unnumbered}

\(1\) Call 911 or pull alarm device box. Give name and specific
location.

\(a\) Small fires can be extinguished without evacuation. However, our
fire plan requires evacuation upon hearing a fire alarm.

(b) Never enter a room that contains visible smoke.

(c) Never enter a room containing visible fire without a back-up person
    on site.

(d) Never enter a room if the door is warm to the touch.

\(2\) [R.A.C.E.]{.underline}

\(a\) RESCUE - Alert people in the area to evacuate, assist anyone
unable to evacuate on their own.

(b) ALARM - Pull nearest fire alarm and call 911.

\(c\) CONFINE - Close doors to confine fire.

(e) EXTINGUISH -- Smother fire or use fire extinguisher.

\(3\) [PASS Fire Extinguisher Usage]{.underline}

> \(a\) Pull pin on extinguisher

(b) Aim at base of fire

(c) Squeeze handle

\(d\) Sweep extinguisher across base of fire

EVACUATE IMMEDIATELY IF FIRE CANNOT BE CONTROLLED!!!!

### PART D MEDICAL EMERGENCY {#part-d-medical-emergency .unnumbered}

(1) Call 911; give name and specific location.

(2) Attend to injured or contaminated persons and evacuate if necessary.

(3) Initiate lifesaving measures, and if required, WEAR PROTECTION.

(4) Do not move injured person unless there is danger of further harm.

### PART E RADIATION SPILL {#part-e-radiation-spill .unnumbered}

\(1\) Call 911. Spreading of radiation beyond the spill area can easily
occur by the movement of personnel involved in the spill or clean-up
effort. Prevent spread by confining movement of personnel until they
have been monitored and found free of contamination. Place absorbent
paper towels over liquid spill. Place towels dampened with water over
spills of solid materials. WEAR PROTECTION.

###  (2) Major Radiation Spill -- Definition: greater than 100 microcuries {#major-radiation-spill-definition-greater-than-100-microcuries .unnumbered}

\(a\) Attend to injured persons and remove them from possible exposure.

(b) Alert people in the laboratory to evacuate.

(c) Have potentially contaminated personnel stay in one area until they
    have been monitored and shown to be free of contamination.

(d) Call Radiation Spill Emergency Response number (911).

(e) Close doors and prevent entrance into affected area.

\(f\) Have person knowledgeable of incident and laboratory assist
emergency personnel.

\(3\) [Minor Radiation Spill]{.underline} -- Definition: less than 100
microcuries

> \(a\) Alert people in immediate area of spill.

(b) Notify Radiation Safety Officer at 713/794-7188 and indicate
    identity of isotope, chemical carrier and activity.

\(c\) Wear protective equipment including safety goggles, gloves, shoe
covers and long-sleeve lab coat.

> \(d\) Place absorbent paper towels over liquid spill.
>
> \(e\) Place towels dampened with water over spills of solid materials.
>
> \(f\) Using forceps, place towels in plastic bag.
>
> \(g\) Dispose in radiation waste container.

\(h\) Monitor area, hands, and shoes for contamination with an
appropriate survey meter or method.

\(i\) Repeat clean up until contamination no longer detected.

[Additional Information]{.underline} -- Contaminated clothing should be
removed for evaluation by the Radiation Safety Officer. If the spill is
on the skin, flush thoroughly or shower, then wash with a mild soap and
lukewarm water.

CHAPTER 2 DISASTER RESPONSE GUIDE

### PART A COMMUNITY EMERGENCY {#part-a-community-emergency .unnumbered}

Such an emergency would include fire, explosion, plane crash, tornado,
hurricane, flood, and earthquake. Upon activation of the Community
Casualty Plan by the Medical Center Director, report, when notified, to
a designated area for instructions.

### PART B CIVIL DEFENSE DISASTER {#part-b-civil-defense-disaster .unnumbered}

Such an event would include nuclear fallout from a bombing, accident, or
military casualties. As circumstances dictate, the Community Casualty
Plan will be effected. Report, when notified, to a designated area for
instructions.

### PART C CIVIL DISTURBANCE {#part-c-civil-disturbance .unnumbered}

Such a disturbance would include a riot, acts of massive violence
causing casualties in the community, or individuals threatening
violence. Notify VA Police at 911. If you are not at risk, gather
descriptive information about the offenders, names, places, etc. Report
all collected information to the VA Police.

### PART D BOMB THREAT {#part-d-bomb-threat .unnumbered}

(1) When a bomb threat is received, the individual receiving the threat
    shall ASK CALLER questions contained in Appendix A. Get as much
    details as possible.

(2) When the call is terminated, call 911 and alert people in the area
    to evacuate to a safe location.

(3) Take the completed "Bomb Threat Telephone Report" to the on-duty VA
    Police Officer.

### PART E MAJOR POWER, UTILITY, OR COMMUNICATIONS DISRUPTIONS {#part-e-major-power-utility-or-communications-disruptions .unnumbered}

(1) Notify VA Police at 911 and Facilities Management Service at
    713/791-1414, x-5884.

(2) Turn off gas valves and powered equipment.

(3) If animals are affected, contact the Research Administration Office
    at 713/794-7566 to assist in moving animals to Baylor College of
    Medicine.

### PART F SEVERE WEATHER EMERGENCY {#part-f-severe-weather-emergency .unnumbered}

Await MEDVAMC Medical Center Director instructions via the Command
Center. If necessary, the Command Center will arrange sleeping/food. Do
not venture into an inclement environment without a clear understanding
of the potential hazards. In the event of a hurricane, the Vivarium
Hurricane Disaster Plan, briefly discussed in Chapter 6, will be
activated as pertains to the welfare of animals.

PART G [BIOTERRORISM READINESS]{.underline}

The MEDVAMC and other healthcare facilities may be the initial sites of
recognition and response to bioterrorism events. If a bioterrorism event
is suspected, local emergency response systems will be activated.

Bioterrorism may occur as covert events, in which persons are
unknowingly exposed and an outbreak is suspected only upon recognition
of unusual disease clusters or symptoms. Bioterrorism may also occur as
announced events, in which persons are

warned that an exposure has occurred.

CHAPTER 3 UNIDENTIFIED ODOR POLICY

[15-MINUTE POLICY ON UNIDENTIFIED ODORS]{.underline}

The 15-minute policy is necessary when odors are detected but the source
is unknown. In the first 5 minutes that an unidentified smell/odor is
detected, the individual should try to determine the origin. If the
odor/smell is associated with coughing, sneezing, shortness of breath,
eye tearing or any other adverse reactions, immediately call 911 and
report the circumstances. Individuals may ask others in the local area
for their assistance in locating the source of the odor. In any case, if
the source cannot be located, call 911 and report the order in 15
minutes or less. In some circumstances, the odor will be identified and
the individual has the responsibility to question risks of hazards. For
answers to questions about the hazards, call the Safety Manager at
713/794-7396.

CHAPTER 4 EMERGENCY RESPONSE GUIDELINES

PART A [THE CASCADE SYSTEM FOR EMERGENCY CALLS IS AT APPENDIX
B]{.underline}. Activation is by:

(1) An individual who has seen or heard something that would indicate an
    impending or actual emergency situation.

(2) The Houston Fire Department

(3) The Houston Police Department

(4) Civil Defense Office

\(5\) Center for Comparative Medicine, Baylor College of Medicine

\(6\) VA Police notification

\(7\) VA Research Administration notification

Once the Emergency Response Plan is activated, primary notification to
Research Service Line personnel will be via word of mouth.

PART B [EVACUATION OF PERSONNEL]{.underline}

\(1\) Horizontal: Moving persons laterally away from the site of danger
to the outside.

\(2\) Vertical: Moving persons down the closest/safest stairwell.

Elevators SHALL NOT BE USED during an evacuation.

PART C [SECURITY SYSTEM]{.underline}

Buildings 109 and 110 are secured and access-controlled 24 hours a day,
7 days a week, including weekends and holidays. Employees in Buildings
109 and 110 needing an ambulance crew, firemen, or other emergency
response personnel are to pull the fire alarm device box -- even if
there is no fire. The fire alarm is the fastest and most reliable way to
inactivate all of the door locks simultaneously.

Immediately notify the Research Office at 713/794-7564 or 713/794-7566
of the nature of the emergency.

CHAPTER 5 EVACUATION OF PERSONNEL WITH DISABILITIES

#  {#section-1 .unnumbered}

# PART A **PROCEDURES** {#part-a-procedures .unnumbered}

#  {#section-2 .unnumbered}

#  (1) Each floor will have two designated evacuation stations with signs that are clearly marked and near a telephone. People with disabilities will be trained as to their location as well as this plan. {#each-floor-will-have-two-designated-evacuation-stations-with-signs-that-are-clearly-marked-and-near-a-telephone.-people-with-disabilities-will-be-trained-as-to-their-location-as-well-as-this-plan. .unnumbered}

\(2\) There will be four employees and two alternate employees per floor
who are trained in the evacuation of disabled persons herein referred to
as evacuators.

\(3\) Designated staff for the service line components will be notified
by the person with disabilities of his or her destination within the
building. The designated staff will then be responsible for ensuring
that all persons with disabilities know the location of the evacuation
stations on the floor of their destination.

\(4\) The designated staff will then notify one of the four trained
evacuators that a person with disabilities will be on their floor and in
which room they will be waiting.

\(5\) When a fire alarm is sounded, the evacuators on the floor will go
to the location or workstation of the person with disabilities on their
floor.

\(a\) If the person with disabilities is found, he/she should be
evacuated immediately to a safe place outside.

\(b\) If the person with disabilities is not located there or in a
nearby area, the evacuators should go to their respective evacuation
stations (two evacuators to a station).

(c ) After waiting a reasonable length of time (two minutes, if
possible) depending on the situation, the evacuators should leave the
area themselves, unless they are contacted by the designated staff and
are advised of that person's location and can get to him/her, conditions
permitting.

\(d\) Once the person with disabilities reaches the evacuation station,
one of the evacuators should call their staff designee and advise that
the person with disabilities is on his/her way to safety. When the
person with disabilities is accounted for, the staff designee will
contact any waiting evacuators so that they can proceed to a safe place.

\(6\) The evacuators should work with the person with disabilities to
determine the best method of transport for that individual. If the
person with disabilities is found unconscious, the evacuators should
appraise the situation and use whatever techniques they deem safest and
most expedient for the circumstances at that moment.

CHAPTER 6 VIVARIUM EMERGENCY

PART A **[ANIMAL EMERGENCY]{.underline}**

\(1\) Animal temperature emergency procedures: Temperature exceeds 85
degrees or is less than 60 degrees in hallway.

\(2\) During normal working hours, the Vivarium staff notifies
Facilities Management Service (713/791-1414, x-5884) that the
temperature is high or low and also notifies Research Administration
(713/794-7566).

\(3\) During off-hours, the VA Police monitor the temperature. If the
temperature is noticed to exceed limits, Facilities Management Service
is called to assess the situation. If the problem is not resolved, the
Facilities Management Service Line Executive (713/794-7138) is notified,
as is the Director of Operations for Research (713/794-7564) and/or the
Associate Chief of Staff for Research (713/794-7566).

\(4\) [Evacuation.]{.underline} In the event of immediate
life-threatening disaster, refer to the MEDVAMC Research and Development
Safety Manual. Do not evacuate animals. If there is no immediate
life-threatening disaster, but knowledge of an impending problem, i.e.,
toxic fumes, possibility of smoke, or other damage spreading to the
Vivarium in the near future, gain permission of the person in charge
(e.g., Fire Chief, VA Police, etc.) to evacuate animals as follows:

\(a\) To laboratories already approved to use animals.

\(b\) Center for Comparative Medicine, Baylor College of Medicine

If the situation poses no threat to human life, remain with relocated
animals. Following the disaster, return the animals to the Vivarium or
move to location determined by the Vivarium Supervisor and continue
animal care.

\(5\) [Hurricane emergency response.]{.underline} Welfare of animals
housed in the Vivarium is the primary concern in the event of a weather
emergency. The MEDVAMC Vivarium Hurricane Emergency Response Plan
describes preparatory and ride-out policies and procedures to ensure
adequate animal care up to, during, and following the emergency.
Readiness levels include the following:

\(a\) LEVEL I is the normal state of readiness maintained throughout the
year. During this time, planning, assessment, and review of service line
and institutional plans occurs.

\(b\) LEVEL II is initiated when there is a high probability that a
severe weather condition will pose a threat to the MEDVAMC.

(c ) LEVEL III is initiated for completion of all protective measures to
ensure that the Vivarium is in a final state of readiness. Level III is
completed when all non-essential personnel have been evacuated.

\(d\) LEVEL IV is initiated for ride-out and post-storm activities.

PART B **[SECURITY BREACH PROCEDURES]{.underline}**

Alarm systems are monitored for breaches. The VA Police will investigate
all breaches and notify the Director of Operations for Research of any
intrusions. The Houston Police is also notified as specified in VA
Police Security and Law Enforcement Policy, when necessary. If there is
resultant damage to the facility, the Director of Operations for
Research and the Public Affairs Officer are notified in addition to
regular VA Police notifications. All questions from the press are
referred either to the Public Affairs Officer or, if unavailable, to the
Director of Operations for Research. No other staff is to discuss the
event with the press.

CHAPTER 7 CYBER SECURITY

PART A [SECURITY MEASURES]{.underline}

For all employees who are involved with the management, use, or
operation of automated information systems in the Research Service Line,
the following necessary practices must be adhered to as assurance that
cyber security controls are in place to protect our information systems
from malicious intent. *NOTE: Computers connected to the Baylor College
of Medicine intranet must also adhere to relative Baylor College of
Medicine Information Technology Security policies.*

##### Networks

\(a\) Establish a network infrastructure dedicated to the control of all
network elements.

\(b\) Ensure that all systems are authenticated and protected.

(c ) Implement protection against denial of access.

#####  (2) Servers and clients {#servers-and-clients .unnumbered}

\(a\) Include the exclusive use of securable operating systems on all
servers and workstations.

\(b\) Ensure security hardened operating systems configurations.

\(c\) Establish "least privilege" based access permissions for users and
operators.

> \(d\) Establish auditing procedures

\(e\) Ensure secure centralized administration

#####  (3) Boundary protections {#boundary-protections .unnumbered}

\(a\) A tightly constrained host configuration to stop dangerous
protocols

and unauthorized access.

\(b\) Elimination of all unprotected backside access within enclaves,
e.g., stand-alone/internal PC modems and dedicated, but otherwise
unprotected, site-to-site circuits.

##### Intrusion detection devices

> \(a\) Network-based monitoring for intrusion detection at enclave
> boundaries.

\(b\) Host-based monitoring.

\(c\) Intrusion detection to counter compromise from the distant end.

\(d\) Centralized and automated intrusion monitoring and incident
reporting.

#####  (5) Online virus protection {#online-virus-protection .unnumbered}

\(a\) Centralized malicious code protection for email, web traffic, and
file transfers.

\(b\) Malicious code protection on all servers and workstations
(including mobile users and remote/home offices) that screens exchanges
of email, web traffic, and files

(c ) Screening of all applications and files prior to each use, and
regular malicious code screening of locally stored files and
applications.

\(d\) Centralized and automated updating of virus scripts and anti-virus
software.

\(6\) [Software and Data Security.]{.underline}

\(a\) Establish safeguards to detect and minimize inadvertent or
malicious modification or destruction, or attempts to do so, of
application software, operating system software, and critical data
files.

\(b\) At a minimum, back up essential data and store in a location
physically separate from the automated information systems. Implement
appropriate physical and environmental controls to ensure viability of
such back-ups.

\(7\) [Hardware Security.]{.underline} Ensure security measures are
taken to protect against theft and unauthorized use of automated
information systems peripheral and communications devices,
microcomputers, laptops, and related items such as printers, floppy
disks, and software.

\(8\) [Physical Security]{.underline}. Controlled and restricted areas
are to be protected by physical security as appropriate for the
sensitivity or criticality of the system.

\(a\) Limit access to controlled areas to those individuals having an
official need to be in the area.

\(b\) Contract maintenance personnel, and others, not authorized
unrestricted access, will be escorted by an authorized person at all
times when they are within the controlled area.

(c ) Media used to record and store sensitive software or data is to be
externally identified, protected, controlled, and secured when not in
actual use.

PART B [CYBER SECURITY INCIDENT]{.underline}

A cyber security incident is any event, suspected event, or
vulnerability that could pose a threat to the integrity, availability,
or confidentiality of information systems' applications or data. In the
event of suspicious activity or cyber attack:

\(1\) Promptly report the incident to the Information Security Officer
at 713/794-7915.

(1) Disable nonessential ports and services

(2) Perform preliminary investigation of all affected systems

(3) Raise awareness within the cyber environment

\(5\) Increase monitoring efforts

PART C [COMPUTER SYSTEM FAILURE]{.underline}

Should the computer systems fail, staff shall manually document staff
presence for payroll purposes. All correspondence and documents (that
would otherwise be prepared using computer software) shall be prepared
manually. The Research Information Technology Specialist will coordinate
data retrieval efforts with the MEDVAMC Information Security Officer and
Information Management Service Line, as appropriate.

APPENDIX A

[BOMB THREAT TELEPHONE REPORT]{.underline}

Complete this questionnaire after receiving a bomb threat.

Date: Time: Call Received: Call Ended:

Exact words of Caller:[\
]{.underline}

Questions to ask:

-   When will it explode?

-   Where is it located? Building Floor Area Room

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-   What kind of bomb is it?

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```
-   What will make it explode?

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```
-   When is it going to explode?

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```
-   How do you detonate it?

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```
-   What does it look like?

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```
-   Why kill or injure innocent people?[\
    ]{.underline}

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```
-   Why was it put there?

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```
-   What is your name?

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```
-   Address?

Description of Voice:

Male Female Calm Nervous

Young Middle Age Old

Speech: Rough Refined Accent

Speech Impediment (describe)

Unusual phrases

Recognize voice? If so, who do you think it was?

Background Noise:

Music Running Motor (type) Traffic Whistles

Bells Horns Aircraft Tape Recorder

Machinery Other

Did the caller indicate knowledge of the facility?

If so, how?

Remarks:

DELIVER BOMB THREAT REPORT TO MEDICAL CENTER POLICE IMMEDIATELY\
(Building 100, Room 1A-820)

APPENDIX B

###### CASCADE FOR EMERGENCY {#cascade-for-emergency .unnumbered}

The cascade list for emergency calls, which includes office as well as
home telephone numbers, is maintained by the Research Administration
Office and will be updated as often as necessary to keep all critical
data current.

An emergency notification system is used to summon assistance during
administrative and non-duty hours. The Associate Chief of Staff for
Research will notify key staff (or their designated alternates) as
outlined in the current cascade roster. Key staff, in turn, will notify
remaining staff as outlined in the current cascade roster.