03.11.04: Risk Response

To meet the 03.11.04: risk response requirement, you must define how your organization will treat identified risks to CUI-bearing systems, make and document risk response decisions (accept, mitigate, transfer, avoid), assign owners and due dates, and retain evidence that actions were completed and monitored over time ¹.

Key takeaways:

• Treat risk response as a managed workflow with decision criteria, approvals, owners, and deadlines, not a one-time risk register update ¹.
• Auditors look for traceability from risk identification to documented response and completed remediation evidence ¹.
• “Accepted risk” still requires a rationale, approval, and ongoing review cadence tied to CUI impact ¹.

03.11.04 sits in the risk management family of NIST SP 800-171 Rev. 3 and is easy to misunderstand because teams often stop after “we did a risk assessment.” Assessors rarely fail you for having a risk register. They fail you when risks don’t drive action, or when action happens but you cannot show a controlled decision, authorization, and follow-through.

Operationalizing 03.11.04 means turning risk findings into a repeatable set of response decisions with clear accountability: what response you chose, why that response is appropriate for CUI, who owns it, when it will be completed, how you verified it, and how you’ll confirm risk stays within tolerance. This requirement also becomes your bridge to related security work: POA&Ms, exception handling, security change management, third-party risk decisions, and budget prioritization.

If you run a CUI environment, you should assume examiners will test a sample of risks and ask you to prove end-to-end closure. Your goal is simple: make risk response decisions in a controlled way, then make those decisions auditable.

Regulatory text

Requirement: “NIST SP 800-171 Rev. 3 requirement 03.11.04 (Risk Response).” ¹

Operator interpretation: You need a defined process to respond to risk. “Respond” means more than recording a risk; it means selecting a treatment option, documenting the decision, and executing it with evidence. The response must be appropriate to your environment that processes, stores, or transmits CUI, and it must be repeatable across risk sources (assessments, incidents, audit findings, third-party issues) ¹.

Plain-English interpretation (what the requirement demands)

03.11.04 expects a closed-loop workflow:

1. A risk is identified and recorded.
2. You decide what to do about it using a defined set of response options.
3. You assign an owner and timeline.
4. You track progress.
5. You keep evidence that the response happened and you revisited the residual risk ¹.

A practical way to phrase it for internal policy: “All identified risks affecting CUI systems must receive a documented response decision, management approval as required, and tracked actions through completion or periodic re-approval for accepted risk.” ¹

Who it applies to (entity and operational context)

Entities: Organizations operating nonfederal systems handling CUI, including federal contractors and subcontractors where NIST SP 800-171 is a contractual requirement ¹.

Operational scope:

• Information systems and services that process, store, or transmit CUI.
• Supporting processes that change risk posture: vulnerability management, configuration management, IAM, incident response, third-party onboarding, and exception management ¹.

Teams involved: CISO/security, compliance/GRC, IT operations, system owners, engineering, procurement/third-party risk, and business owners who can accept residual risk for their functions.

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

Step 1: Define your risk response options and decision criteria

Create a short, enforceable standard that defines the only allowable treatments:

• Mitigate (implement or improve controls)
• Accept (approve residual risk)
• Avoid (stop the activity or remove exposure)
• Transfer/share (contractual transfer, insurance, outsourced service with compensating controls)

Add decision criteria tied to CUI impact (confidentiality focus) and operational constraints ¹. Keep it specific enough that two reviewers reach the same conclusion most of the time.

Minimum fields to require: risk statement, affected system/CUI boundary, impact narrative, likelihood narrative, inherent risk rating method, chosen treatment, residual risk rating, rationale, approver, owner, due date, verification method, status.

Step 2: Establish authority and approvals (who can accept what)

Write a simple RACI:

• Risk owner: system owner or business owner accountable for the exposure.
• Control owner: team implementing remediation (SecOps/IT/Engineering).
• Approver: role authorized to accept residual risk (often business executive with CISO concurrence).
• GRC: ensures the workflow is followed and evidence is retained ¹.

Avoid “security approves everything” if the business owns the risk. The security team should advise and validate, but acceptance should sit with accountable leadership.

Step 3: Connect risk response to a tracked execution mechanism

Pick the mechanism that is already auditable in your environment:

• A GRC ticket/workflow, or
• A POA&M-style tracker tied to control gaps, or
• A formal exception process for accepted risk

The key is traceability from risk record → response decision → tasks → completion evidence ¹.

Practical mapping:

• “Mitigate” becomes one or more remediation tasks with control references and test steps.
• “Accept” becomes a time-bound exception with explicit residual risk and review date.
• “Avoid” becomes a change request to remove a feature, data flow, or connectivity.
• “Transfer” becomes a contract requirement plus verification (attestation, audit report, or control testing), and a residual risk review.

Step 4: Set review triggers and cadence (what forces re-evaluation)

Define events that require you to revisit a risk response:

• Material system change (new integrations, identity model changes, major upgrades)
• Significant vulnerabilities or exploit activity relevant to your stack
• CUI boundary changes (new programs, new CUI categories, new subcontractors)
• Incident or near-miss indicating control failure
• Audit/assessment findings ¹

For accepted risks, require a periodic re-approval. Keep it role-based and evidence-based, not calendar theater.

Step 5: Build assessment-ready sampling and reporting

Expect an assessor to pick a handful of risks and ask for end-to-end proof. Prepare a standing “audit packet” view that shows:

• Top risks to CUI systems by rating
• Overdue remediation items
• Accepted risks and next review date
• Evidence links per item ¹

If you use Daydream, configure the control mapping so each risk response record links to the relevant policy language, control(s), and recurring evidence requests. That reduces scramble work and forces consistent artifacts across risk owners.

Required evidence and artifacts to retain

Assessors rarely accept “we discussed it in a meeting.” Keep artifacts that show decisions and execution ¹:

Core artifacts

• Risk response procedure/standard (approved, versioned)
• Risk register with required fields populated
• Risk acceptance/exceptions register with approvals
• POA&M or remediation tracker entries tied to specific risks

Execution evidence ¹

• Approval record (ticket approval, signed memo, or workflow log)
• Remediation evidence: configuration screenshots, change tickets, deployment records, test results, updated baselines, vulnerability scan deltas
• Validation evidence: control test, internal audit result, or security verification notes
• Residual risk review notes and decision outcomes

Third-party related

• Contract clauses/SOW security requirements tied to the response
• Third-party assessment results or attestations, if transfer/share is selected

Common exam/audit questions and hangups

Auditors tend to probe the same failure points ¹:

• “Show me a risk you accepted. Who approved it and why was acceptance appropriate?”
• “Pick one high risk. Show evidence the mitigation happened and reduced residual risk.”
• “How do you ensure risk owners don’t ignore overdue actions?”
• “How do you treat third-party risks that affect CUI workflows?”
• “How do you know your risk response process is operating, not just documented?”

Hangup: “We have a spreadsheet.”
A spreadsheet can work if it has approvals, task tracking, and evidence links. Most don’t.

Frequent implementation mistakes (and how to avoid them)

1. Mistake: treating ‘accept’ as ‘ignore.’
   Fix: require documented rationale, explicit residual risk, named approver, and a re-approval trigger ¹.

2. Mistake: remediation work happens, but there’s no evidence chain.
   Fix: mandate evidence attachments per risk response task as a “definition of done.”

3. Mistake: no consistent risk statements.
   Fix: standardize format: “If [threat], then [impact] because [vulnerability/control gap] on [system/CUI flow].” This makes response decisions defensible.

4. Mistake: third-party risks are stored elsewhere and never reconciled to CUI risk.
   Fix: require a linkage field from third-party findings to internal CUI system risks and response actions.

5. Mistake: GRC owns all responses.
   Fix: GRC owns the process; system and business owners own the risk and actions.

Enforcement context and risk implications

No public enforcement cases were provided for this requirement in the supplied source catalog. Practically, the risk is contractual and assessment-driven: weak risk response creates sustained, known control gaps in CUI environments, which increases the chance of CUI exposure and makes it hard to defend your security posture during customer audits or certification-style reviews ¹.

Practical execution plan (30/60/90)

You asked for speed. Use phases to avoid false precision while still driving action.

First 30 days (stand up the workflow)

• Publish a one-page risk response standard: treatments, required fields, approval roles, evidence expectations ¹.
• Inventory current risk sources: assessments, vulnerability findings, incidents, audit issues, third-party reviews.
• Implement a single system of record (GRC tool or ticketing) with mandatory fields and an approval step for accept/transfer.
• Train risk owners with two examples: one mitigation, one acceptance.

Days 31–60 (make it operate)

• Run a risk response working session with system owners for top CUI systems. Convert findings into response decisions and tasks ¹.
• Define and launch a lightweight monthly risk review agenda: overdue items, accepted risks up for review, new high-impact risks.
• Add evidence checklists to remediation ticket templates so teams attach proof as they work.

Days 61–90 (make it auditable)

• Perform an internal “mock assessment” sample: pick risks and test traceability from identification through closure evidence ¹.
• Tighten approval thresholds and RACI based on what broke in practice.
• If you use Daydream, set recurring evidence requests for: accepted risk reviews, remediation validation, and control test results tied to 03.11.04 mappings.

Frequently Asked Questions

What counts as an acceptable “risk response” for 03.11.04?

A risk response is a documented treatment decision (mitigate, accept, avoid, transfer/share) with an owner, approval when needed, tracked actions, and evidence of completion or re-approval for accepted risk ¹.

Can we meet 03.11.04 with a spreadsheet?

Yes, if the spreadsheet enforces required fields, captures approvals, tracks tasks to closure, and links to evidence artifacts per risk ¹. Most teams fail on approvals and evidence, not on the format.

Who should be allowed to accept risk?

The person accountable for the business outcome and CUI exposure should accept residual risk, typically with security review or concurrence ¹. Document the role and approval path in your standard.

How do we handle third-party risks under this requirement?

Treat third-party findings as first-class risks when they affect CUI systems or flows, and record a response decision with contract actions, compensating controls, and verification evidence ¹.

What evidence do assessors ask for most often?

They ask for traceability: the risk record, the response decision and approval, the remediation or exception ticket, and proof the response reduced or bounded the risk ¹.

How do we show that “accepted risks” are still controlled?

Require a written rationale, explicit residual risk, approver identity, and a documented review trigger or periodic re-approval record ¹.

Footnotes

1. NIST SP 800-171 Rev. 3