03.15.01: Policy and Procedures

To meet the 03.15.01: policy and procedures requirement, you must formally document, approve, publish, and maintain policies and supporting procedures that govern how your environment protects CUI, and you must be able to prove those documents drive real, repeatable operational behavior. Operationalize it by mapping policy statements to system boundaries, control owners, measurable steps, and recurring evidence tied to your SSP and POA&M. ¹

Key takeaways:

• Write policies that set “what and why,” and procedures that define “who does what, how, and how often,” for your CUI environment. ¹
• Make the requirement auditable: map each policy/procedure to SSP control statements, system components, owners, and evidence. ¹
• Treat gaps as governed work: track them in a POA&M with target dates, risk ratings, and closure validation before you call them done. ¹

03.15.01 is a “paper meets production” requirement. Assessors expect to see written direction (policy), actionable work instructions (procedures), and proof those instructions are followed in the systems and processes that handle Controlled Unclassified Information (CUI). If your documentation exists but is generic, out of date, or disconnected from how admins and users actually operate, you will struggle to defend implementation.

For a Compliance Officer, CCO, or GRC lead, the fastest path is to build a tight documentation chain: Requirement → policy statement → procedure steps → system/control mapping in the SSP → operational evidence → gap tracking in the POA&M. That chain lets you answer the hard questions quickly: “Where does this apply?”, “Who owns it?”, “Show me it’s operating,” and “What’s the plan for anything not yet met?” ¹

This page focuses on requirement-level execution. You’ll get practical steps, the artifacts to retain, common audit hangups, and an execution plan you can hand to control owners without rewriting everything from scratch. ¹

Regulatory text

Excerpt (as provided): “NIST SP 800-171 Rev. 3 requirement 03.15.01 (Policy and Procedures).” ¹

What the operator must do: Establish and maintain security policies and procedures for the controls in scope for your CUI environment, keep them current, ensure they are approved and communicated, and be able to show they are used to run the program. In practice, auditors will test whether your written policies/procedures match actual technical configurations, administrative workflows, and recurring reviews captured in evidence. ¹

Plain-English interpretation (what 03.15.01 really demands)

• Policy is management intent and non-negotiable rules: scope, objectives, roles, and governance. It answers “what do we require and why.”
• Procedures are repeatable instructions that a person can execute: steps, tools, frequency, approvals, escalation, and recordkeeping. They answer “how do we do it here.”

A passing implementation is not “we have a security policy.” A passing implementation is: each relevant practice in your CUI scope is governed by an approved policy and a working procedure, and you can show evidence that people followed the procedure. ¹

Who it applies to (entity and operational context)

This requirement applies when you are a nonfederal organization operating systems that process, store, or transmit CUI, commonly in a federal contractor/subcontractor context. ¹

Operationally, it applies to:

• The CUI system boundary (your defined environment where CUI lives).
• The teams that run it: IT, security, cloud/platform, endpoint, identity, networking, app teams, help desk, and any managed service providers touching in-scope systems.
• Third parties with administrative access, hosting responsibilities, or CUI handling obligations, because your procedures must define how you govern and evidence their work as part of your environment. ¹

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

1) Define the documentation scope to match your CUI boundary

1. Confirm your CUI boundary statement (what systems, identities, networks, and locations are in scope).
2. Build a control inventory list for in-scope practices and identify which ones need explicit policy/procedure coverage.
3. Decide your documentation structure:
   • One enterprise security policy + domain procedures, or
   • A CUI-specific policy set tied to the SSP.

Exam focus: If scope is fuzzy, your policies/procedures will be either overbroad (not provable) or too narrow (miss in-scope reality). ¹

2) Write (or refactor) policies so they are testable

Minimum policy elements you should include:

• Purpose and scope (explicitly mention the CUI environment).
• Roles and accountability (named functions, not names).
• High-level requirements (what must happen).
• Exceptions process (who can approve, how to record).
• Review/approval cadence (set an internal cadence and follow it).
• References to procedures and standards.

Practical tip: Keep policy language stable. Put tool-specific or step-by-step content in procedures so you can change execution without constant policy re-approval.

3) Build procedures that can be executed and evidenced

For each policy requirement, define procedures with:

• Trigger (event-based) and frequency (calendar-based) activities.
• Step-by-step actions and the systems/tools used.
• Required approvals (ticket approvals, change reviews).
• Required records (what evidence is produced, where it is stored).
• Escalation path for failures and overdue tasks.

Example (procedure evidence definition):

• “User access reviews are performed” becomes:
  • Step: Export access list from IAM tool; validate against HR roster; record approvals in ticketing system; remediate exceptions; save export and sign-off.
  • Evidence: export file, approval record, remediation tickets, exception log. ¹

4) Map everything to the SSP, owners, and system components (make it assessable)

Create a mapping table (this is where most programs mature fast):

Requirement / Control area	Policy statement ID	Procedure ID	Control owner	In-scope systems/components	Evidence produced	Where evidence lives

Your goal is to remove interpretation risk for assessors. They should not have to guess which document governs which practice, or where proof is stored.

This is also where Daydream fits naturally: teams use it to maintain control mappings across SSP narratives, owners, and evidence requests so audits stop becoming spreadsheet archaeology.

5) Define measurable implementation criteria (avoid “checkbox” language)

Turn “we do X” into “we can show X occurred”:

• What artifact is generated each time?
• Who approves it?
• What constitutes “pass/fail”?
• What is the remediation path?

This supports consistent evidence collection and reduces “oral tradition” compliance. ¹

6) Run a documentation-to-reality validation (spot gaps before the assessor does)

Do a tabletop walkthrough with each control owner:

• Pull the policy + procedure.
• Identify the exact system screens/logs/tickets produced.
• Collect a small sample of evidence.
• Record mismatches as gaps.

7) Track gaps in a POA&M with closure validation

For anything not fully implemented:

• Record the gap in a POA&M with a target date, risk rating, and owner.
• Define closure criteria (what evidence proves it is fixed).
• Do not mark complete until closure evidence is attached and reviewed.

Assessors look for active remediation governance, not perfect maturity. They also look for honesty and traceability. ¹

Required evidence and artifacts to retain

Keep artifacts in a controlled repository with versioning and access controls. Recommended minimum set:

• Approved policy documents (with version history and approvals).
• Procedures/runbooks (with last review date and owner).
• SSP mappings that link requirement → policy/procedure → implementation statement → system components. ¹
• Control ownership list (RACI-style is fine).
• Evidence register (what evidence exists, period covered, location).
• Operating evidence examples (tickets, change records, review sign-offs, exports, logs, scan results, training attestations) that correspond to your procedures. ¹
• POA&M entries for known gaps, with closure evidence and management sign-off on completion. ¹
• Exception register (approved deviations with expiration dates and compensating controls).

Common exam/audit questions and hangups

Expect these lines of questioning:

• “Show me the policy and the procedure that governs this requirement in your CUI boundary.” ¹
• “Who is accountable, and where is that documented?”
• “Prove the procedure operated recently. Where is the evidence?”
• “Does your SSP narrative match your procedures, tools, and current architecture?”
• “What happens when the procedure can’t be completed on time? Show escalation and tracking.”
• “How do you control and review exceptions?”

Hangups that cause delays:

• Procedures exist but are not followed; teams “do it ad hoc.”
• Evidence is scattered across email and chat, then lost at assessment time.
• The SSP says one tool/process; reality uses another.
• POA&M items have vague closure criteria, so nothing is truly “done.” ¹

Frequent implementation mistakes (and how to avoid them)

1. Generic policies with no CUI boundary tie-in
   Fix: add explicit scope language and link to your SSP boundary description. ¹

2. Procedures that describe intent, not steps
   Fix: write procedures so a new admin could execute them, including where to store evidence.

3. No named owners
   Fix: assign a role-based owner per procedure and per evidence set; document it in your mapping table.

4. Evidence collected only during audits
   Fix: adopt an evidence calendar and an evidence register. Make evidence collection part of the procedure itself. ¹

5. POA&M as a parking lot
   Fix: require target dates, closure criteria, and closure evidence review before completion. ¹

Enforcement context and risk implications

No public enforcement case sources were provided in the source catalog for this requirement, so this page does not list specific cases.

Risk still concentrates in predictable places:

• If policies/procedures do not match operations, you get assessment findings that can block contract requirements tied to NIST SP 800-171 alignment.
• If evidence is missing, you cannot prove implementation even if teams “really do it,” and the assessment outcome will reflect what you can demonstrate. ¹

Practical 30/60/90-day execution plan

First 30 days (stabilize and map)

• Confirm CUI system boundary and in-scope owners. ¹
• Inventory existing policies/procedures; mark which are in-scope, outdated, or missing.
• Build the mapping table (requirement → SSP statement → policy/procedure → owner → evidence).
• Create an evidence register and standard naming conventions for artifacts.

Days 31–60 (make procedures executable and start evidence)

• Rewrite the highest-risk procedures into step-by-step runbooks with embedded evidence requirements.
• Run walkthroughs with control owners to validate “documented vs real.”
• Start collecting recurring evidence in the repository; stop storing proof in email.
• Open POA&M items for gaps with clear closure criteria and ownership. ¹

Days 61–90 (prove operation and close gaps)

• Perform an internal mini-assessment: sample evidence against each mapped procedure.
• Reconcile SSP narratives with current tooling and workflows; update where mismatched. ¹
• Drive POA&M closure for items that can be completed quickly; keep longer work governed with milestones.
• Present a management review packet: policy/procedure status, evidence health, open POA&M risks.

Frequently Asked Questions

Do we need separate CUI policies, or can we use enterprise-wide policies?

Either can work if the documents clearly define scope and can be mapped to the CUI boundary and SSP statements. Assessors care less about format and more about traceable applicability and operating evidence. ¹

What’s the minimum difference between a policy and a procedure for 03.15.01?

A policy sets rules, scope, and accountability. A procedure tells a role exactly how to execute the rule and what evidence to save to prove it happened. ¹

How do we prove procedures are followed without generating busywork?

Embed evidence generation into the workflow you already run (tickets, change records, tool exports, approvals). Store it in a consistent repository and reference it in your evidence register. ¹

What should we do if our SSP says one thing, but operations changed tools last quarter?

Update the SSP narrative and mappings to reflect current reality, then align procedures and evidence collection to the new toolchain. Treat the mismatch as a POA&M gap until documentation and evidence match operations. ¹

Can third parties “inherit” our procedures?

They can follow your procedures if the contract and operating model require it and you can collect evidence of their execution. If they operate their own procedures, you still need mapping, oversight, and evidence that their procedures meet your requirements for CUI handling. ¹

What’s the fastest way to get audit-ready for 03.15.01?

Build the mapping table, assign owners, and collect a small set of representative evidence for each major procedure. Audit-readiness comes from traceability and proof, not document volume. ¹

Footnotes

1. NIST SP 800-171 Rev. 3