Roles and Responsibilities

To meet the HITRUST “roles and responsibilities” requirement, you must document security roles for employees, contractors, and third-party users, align them to your information security policy, and communicate those responsibilities before hiring or onboarding. Your goal is provable clarity: who does what, who approves what, and what security duties apply from day one. ¹

Key takeaways:

• Define and document security responsibilities for employees, contractors, and third-party users, not just IT staff. ¹
• Communicate role expectations prior to employment or engagement, then reinforce them at onboarding and access provisioning. ¹
• Auditors will look for consistent role documents, hiring/onboarding evidence, and access-to-role mapping. ¹

“Roles and Responsibilities” sounds basic until you try to prove it under audit. HITRUST expects more than an org chart or a generic job description. You need defined security roles and responsibilities for three populations: employees, contractors, and third-party users. You must document these responsibilities in a way that aligns with your information security policy, and you must communicate them before employment or engagement starts. ¹

Operationally, this requirement sits at the intersection of HR, procurement/third-party management, IT access administration, and security governance. If any of those teams operate informally, you get the classic failure modes: accounts provisioned before onboarding, third parties with ambiguous obligations, or managers who cannot explain who approves access, reviews logs, or signs off on risk. None of those are “technical” problems; they are accountability problems.

This page gives you requirement-level guidance you can put into action immediately: who owns what, the minimum documentation set, how to embed responsibilities into hiring and third-party onboarding, and how to answer common audit questions without scrambling for evidence.

Regulatory text

HITRUST requirement (Roles and Responsibilities): “Security roles and responsibilities of employees, contractors, and third-party users shall be defined and documented in accordance with the organization's information security policy. Roles and responsibilities shall be defined prior to employment and communicated to candidates.” ¹

What the operator must do:

1. Define security responsibilities for all relevant roles across employees, contractors, and third-party users. ¹
2. Document them in a controlled, reviewable format that is consistent with your information security policy (terms, governance, and expectations match). ¹
3. Set expectations before onboarding by communicating responsibilities to candidates or incoming resources prior to employment/engagement. ¹

Plain-English interpretation

You need a written, repeatable way to answer: “For any person who touches our systems or data, what security duties apply to them, and when did we tell them?” This is about accountability and traceability. Job titles are not enough; auditors want to see that security is embedded into role expectations, not tacked on after access is granted.

The “prior to employment” clause is the operational trap. If you only inform people during onboarding training, you may fail the “communicated to candidates” expectation. The clean approach is to include security responsibilities in offer letters, contractor SOWs, and third-party user terms, then confirm acknowledgement at onboarding.

Who it applies to

Entity scope: All organizations pursuing or maintaining alignment with this HITRUST control. ¹

Operational scope (who must be covered):

• Employees (full-time, part-time, temporary staff).
• Contractors (independent contractors, agency staff, staff augmentation).
• Third-party users (any external users with access to your systems, data, facilities, or networks; this can include vendors, partners, customers with privileged access, or managed service provider personnel).

Where it shows up in real programs:

• HR hiring workflows and job requisitions
• Procurement and third-party onboarding
• Identity and access management (IAM) provisioning
• Security training and policy acknowledgement
• Joiner/mover/leaver processes

What you actually need to do (step-by-step)

Step 1: Define a role taxonomy that maps to access reality

Start from how access is granted, not from org charts. Create a short list of “security-relevant roles” that reflect your environment. Examples:

• Workforce end user
• Manager/approver
• System administrator
• Application owner
• Data owner / data steward
• Security incident responder
• Developer / DevOps
• Third-party support user (privileged)
• Third-party business user (non-privileged)

Keep the list small enough to maintain, but granular enough to assign meaningful responsibilities.

Operator check: If you cannot map a person’s access profile to one of your defined roles, your taxonomy is too vague.

Step 2: Write role responsibility statements aligned to your security policy

For each role, document:

• Purpose and scope (what systems/data the role typically touches)
• Security responsibilities (required behaviors and approvals)
• Prohibited behaviors (e.g., account sharing, bypassing controls)
• Required training and acknowledgements
• Escalation and reporting duties (how and when to report incidents, suspected phishing, policy violations)
• Approval responsibilities (who approves access, exceptions, and changes)

Make sure the language matches your information security policy. If your policy says “data owners approve access,” your role documents must reflect that approval chain.

Practical format: A “Role-Based Security Responsibilities Matrix” works well. One row per role; columns for responsibilities, approvals, training, and evidence.

Step 3: Embed responsibilities into pre-employment and pre-engagement communications

You need proof that expectations were communicated before the relationship begins. Implement for each population:

Employees

• Add a “Security Responsibilities” section to job descriptions or requisitions for roles with elevated access.
• Include a security expectations attachment or clause in offer packets.
• Require acknowledgement as part of pre-start paperwork when possible.

Contractors

• Include security responsibilities in the contract/SOW.
• Require acknowledgement of policies before access is provisioned.

Third-party users

• Include responsibilities in third-party terms, onboarding guides, or access agreements.
• For privileged third-party access, require explicit acceptance of monitoring, acceptable use, and incident reporting expectations before account creation.

Control objective: You should be able to show an auditor the exact artifact sent to candidates/third parties and the acknowledgement record.

Step 4: Connect roles to access provisioning (IAM) and approvals

Document how role assignment drives access:

• Define who assigns a person to a role (HR, hiring manager, third-party sponsor).
• Define who approves access for each role (manager, application owner, data owner).
• Ensure role assignment is captured in a system of record (HRIS, IAM, ticketing).

If your IAM supports groups/roles, align technical roles with the documented roles. If not, maintain a mapping table: “Business role → systems → access groups → approvers.”

Step 5: Train, attest, and re-confirm on role changes

Even though the control text emphasizes pre-employment communication, examiners commonly test whether role responsibilities stay accurate.

• Require policy acknowledgement at onboarding.
• Trigger re-attestation when someone changes roles (mover event) or when a third-party changes scope.
• Maintain version control so you can show which responsibilities applied at the time of onboarding.

Step 6: Put governance around it (ownership, review cadence, exceptions)

Assign owners:

• Control owner: Information Security Governance (often GRC)
• Process owners: HR (employees), Procurement/TPRM (third parties), IT/IAM (access)
• Approvers: CISO or delegated security leader for the role matrix

Define:

• How updates are requested and approved
• How exceptions are handled (temporary access, emergency access)
• Where the authoritative documents live and how staff find them

Daydream can reduce the operational drag by centralizing third-party onboarding workflows and evidence capture (role mapping, acknowledgements, access sponsor approvals) so you can produce audit-ready records without chasing emails across HR, IT, and procurement.

Required evidence and artifacts to retain

Auditors typically want consistency across documentation, workflow, and records. Maintain:

Core documents

• Information security policy (referenced by role documents). ¹
• Role-Based Security Responsibilities Matrix (employees, contractors, third-party users). ¹
• Role definitions for privileged roles (admins, developers, incident responders).

Hiring/onboarding evidence

• Job descriptions or candidate communications showing security responsibilities.
• Offer packet or pre-start acknowledgement records (employees).
• Contractor SOW/contract clauses with security responsibilities.
• Third-party user access agreements/terms.
• Onboarding checklist showing role assignment occurred before access provisioning.

Access and governance evidence

• IAM provisioning tickets showing role-based approvals.
• Access sponsor assignments for third-party users.
• Exception approvals and time-bounded access records.
• Document control metadata (version history, approvals).

Common exam/audit questions and hangups

• “Show me where security responsibilities are defined for a contractor and a third-party user.”
  Hangup: organizations only document employee responsibilities.
• “Prove responsibilities were communicated prior to employment/engagement.”
  Hangup: training occurs after start date; no pre-start artifact exists.
• “How do you ensure role changes trigger responsibility updates?”
  Hangup: mover process is informal; no re-attestation.
• “How do responsibilities connect to access approvals?”
  Hangup: approvals are ad hoc; no mapping to role definitions.
• “Who owns this control and how is it maintained?”
  Hangup: unclear ownership between HR, IT, and security.

Frequent implementation mistakes (and how to avoid them)

1. Mistake: Treating this as an HR-only job description exercise.
   Fix: Tie roles to IAM approvals and provisioning evidence. If it doesn’t affect how access is granted, it won’t hold up well in testing.

2. Mistake: Ignoring third-party users.
   Fix: Create third-party user role templates and require a sponsor plus an access agreement before accounts are created.

3. Mistake: “Everyone must follow policies” as the only responsibility statement.
   Fix: Add concrete duties by role: approve access, review logs, protect credentials, report incidents, manage keys, maintain secure configurations.

4. Mistake: Communicating responsibilities only at onboarding.
   Fix: Add pre-engagement language to offers, SOWs, and third-party access terms, then retain acknowledgement.

5. Mistake: No document control.
   Fix: Store role documents in a controlled repository with owners and approvals; keep historical versions for audit lookback.

Risk implications (why auditors care)

Unclear responsibilities produce predictable failures: access approvals without accountable owners, delayed incident reporting, and third-party access that outlives a contract. The risk is operational (confusion during incidents), compliance (inability to prove expectations), and security (privileged access without defined duties). This control is a foundation; weaknesses here often cascade into access control and third-party risk findings.

Practical 30/60/90-day execution plan

First 30 days (stabilize and define)

• Assign control ownership (GRC) and process owners (HR, Procurement/TPRM, IAM).
• Inventory workforce categories: employees, contractors, third-party users with system access.
• Draft a role taxonomy and the first version of the Role-Based Security Responsibilities Matrix.
• Identify which pre-employment/pre-engagement artifacts will carry responsibilities (job description, offer attachment, SOW clause, third-party access agreement).

Next 60 days (embed into workflows and collect evidence)

• Update templates: job descriptions for sensitive roles, offer packet language, contractor SOW clauses, third-party user terms.
• Update IAM provisioning: require “role selection” and “role-based approver” in tickets.
• Build onboarding checklists that confirm responsibilities were communicated and acknowledged before access.
• Run a pilot on one business unit and one high-risk third party; fix friction points.

By 90 days (operate, test, and audit-proof)

• Roll out across the organization; train HR, procurement, and IT approvers on the workflow.
• Perform a sample-based QA review: pick recent hires/contractors/third-party users and verify evidence exists end-to-end.
• Formalize ongoing maintenance: change management triggers for new systems, new roles, and role changes.
• Prepare an audit binder: current role matrix, templates, sample onboarding packets, and access approvals mapped to roles.

Frequently Asked Questions

Do we need separate role definitions for employees, contractors, and third-party users?

You need coverage for all three populations. You can reuse the same role definitions, but you still need contract and onboarding artifacts that apply to each population and prove pre-engagement communication. ¹

What counts as “communicated to candidates” in practice?

Include the security responsibilities in job postings, job descriptions shared during recruiting, or offer packet attachments. Keep a record of what was provided and when, so you can show it occurred before employment starts. ¹

We already have an information security policy. Isn’t that enough?

No. The requirement calls for roles and responsibilities to be defined and documented in accordance with the policy, which implies role-specific expectations, not only a general policy statement. ¹

How do we handle third-party users who access our systems through their employer’s identity provider?

Treat them as third-party users and require an access agreement or terms acknowledgement before enabling access. You still need a sponsor, role assignment, and evidence that responsibilities were communicated pre-access.

What should we show an auditor as “proof” for this control?

Provide the role responsibility matrix, the templates used to communicate responsibilities pre-employment/pre-engagement, and a sample set of onboarding/provisioning records tying individuals to roles and approvals. ¹

Who should own the roles and responsibilities matrix?

GRC or security governance typically owns the document, with HR, procurement/TPRM, and IAM as process owners for embedding it into hiring, contracting, and access workflows. Document those ownership assignments and review/update steps.

Footnotes

1. HITRUST CSF v11 Control Reference