PT-1: Policy and Procedures

PT-1 requires you to create, approve, and distribute formal privacy policy and procedures to the right audiences, then prove they are current and actually used in operations. To operationalize it, assign an owner, publish the documents in a controlled repository, train affected roles, and maintain recurring evidence that procedures drive real workflows. ¹

Key takeaways:

• Write one privacy policy and a set of implementable procedures, then disseminate both to defined audiences. ¹
• Make PT-1 auditable: ownership, version control, approvals, training/acknowledgement, and mapped evidence artifacts. ¹
• Treat PT-1 as the “front door” control that ties your privacy program to day-to-day execution and assessments. ²

PT-1: Policy and Procedures is a documentation-and-dissemination requirement, but assessors rarely score it on writing quality alone. They look for a chain of proof: you developed policy and procedures, documented them with clear ownership and governance, and disseminated them to the people who need to follow them. That “people” question is where teams get stuck, because privacy spans security, product, HR, procurement, and third parties.

In NIST SP 800-53 Rev. 5, PT controls sit in the privacy family, so PT-1 becomes your anchor artifact for privacy control implementation: it explains what the organization requires (policy) and how teams execute it (procedures). If you are a federal system or a contractor system handling federal data, PT-1 is often evaluated alongside your system security/privacy documentation set and your control implementation narrative. ²

This page gives requirement-level guidance you can apply immediately: scope, ownership, a practical build sequence, evidence to retain, and the exam questions that typically surface gaps. Where teams need tooling, Daydream can help you map PT-1 to a control owner, an implementation procedure, and recurring evidence artifacts so you stay assessment-ready without reinventing your documentation set each cycle. ¹

Regulatory text

Requirement (excerpt): “Develop, document, and disseminate to {{ insert: param, pt-1_prm_1 }}:” ¹

What the operator must do

Because the excerpt is parameterized, treat it as a structured obligation with three verbs you must satisfy and evidence for each:

1. Develop privacy policy and procedures (create the content, align to your environment). ¹
2. Document them (approve, version-control, and make them retrievable). ¹
3. Disseminate them to defined audiences (the parameter typically represents roles or groups; your job is to define them and show distribution). ¹

Plain-English interpretation (what PT-1 really demands)

PT-1 expects a usable “privacy playbook.” Your policy states what the organization commits to and what must be true. Your procedures translate that into steps teams can execute (intake, review, approvals, logging, escalation, and exceptions). Dissemination means the right people can find it quickly, understand it, and are expected to follow it.

A strong PT-1 implementation answers these exam questions without scrambling:

• “Where is your privacy policy, who approved it, and when was it last reviewed?”
• “Show me the procedure your engineers/procurement/HR follow for privacy-impacting work.”
• “Prove the procedure is known and used, not sitting in a folder.”

Who it applies to

Entity scope

• Federal information systems implementing NIST SP 800-53 Rev. 5 controls. ²
• Contractor systems handling federal data where NIST SP 800-53 controls are contractually required or used as the control baseline. ²

Operational context (where it shows up)

PT-1 becomes operationally relevant anywhere personal data is:

• Collected (product telemetry, forms, onboarding)
• Used/shared (analytics, marketing, support tools, third parties)
• Stored/retained (data lakes, HRIS, CRM)
• Disposed of (retention schedules, deletion workflows)
• Involved in incident response (breach response intersects privacy)

For third-party risk: PT-1 should connect to procurement and third-party onboarding procedures that address privacy requirements (data processing terms, security/privacy questionnaires, and ongoing monitoring).

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

Step 1: Name the control owner and governance path

• Assign a PT-1 control owner (often privacy officer, CCO, or GRC lead).
• Define approvers (legal/privacy counsel, security, and an accountable executive as appropriate).
• Define where the canonical version lives (GRC system, controlled wiki, document management system).

Operator tip: PT-1 is easier to defend if ownership is explicit and stable across reorganizations. Daydream can track the owner, the procedure link, and the evidence set so ownership changes do not break your audit trail. ¹

Step 2: Draft the privacy policy (one policy, clear commitments)

Your policy should be short enough to read and strict enough to assess. Include:

• Scope (systems, business units, data types)
• Roles/responsibilities
• High-level requirements for data handling, third-party sharing, and lifecycle controls
• Exception management (who can approve deviations and how they’re recorded)

Keep the policy stable; push operational detail into procedures so teams can update workflows without rewriting the policy every time.

Step 3: Write implementable procedures (the “how”)

Create procedures that correspond to your real workflows. Common procedure set:

• Data intake and classification procedure (what data is collected, purpose, approvals)
• Third-party onboarding procedure (privacy/security review gates, contract checks, reassessment triggers)
• Privacy review procedure for new products/changes (intake, risk review, sign-off, recordkeeping)
• Data subject request handling procedure (intake, identity verification approach, routing, response tracking)
• Retention and deletion procedure (triggers, system owners, verification, exceptions)
• Incident/breach coordination procedure (privacy notifications coordination with security/IR)

You do not need perfect maturity on day one, but each procedure must be executable: inputs, steps, decision points, outputs, and where records live.

Step 4: Define “dissemination” audiences and methods

The parameterized audience is the crux. Define it in your PT-1 implementation statement as categories, for example:

• All workforce (policy awareness)
• Privacy, security, and GRC teams (full procedures)
• Engineering/product (procedures relevant to releases, telemetry, data access)
• Procurement/vendor management (third-party procedure)
• HR (employee data handling procedure)

Dissemination methods you can defend:

• Publishing in a controlled repository with access controls and read permissions
• Required training modules or attestations for roles in scope
• Onboarding checklists referencing the documents

Step 5: Map PT-1 to recurring evidence artifacts

PT-1 is often failed on evidence, not content. Build an “evidence register” tied to each procedure:

• Privacy review tickets and approval records
• Third-party due diligence packages and approvals
• Data retention/deletion job logs or deletion requests
• Training completion and policy acknowledgement exports
• Exception logs with approvals

Daydream’s recommended approach is to map PT-1 to a control owner, implementation procedure, and recurring evidence artifacts so you can produce consistent proof on demand. ¹

Step 6: Operationalize with cadence and change control

• Put policy/procedures under document control (versioning, change history, approval workflow).
• Establish a review trigger (material system change, new data use, new third party category, incident learnings).
• Ensure procedures are embedded in tools: ticketing intake forms, procurement workflows, SDLC gates.

Required evidence and artifacts to retain

Use this as your PT-1 audit packet checklist:

Core documents

• Privacy policy (current version + prior versions)
• Procedures (each current version + prior versions)
• Document control metadata (owner, approvers, effective date, revision history)

Dissemination proof

• Training assignment and completion records (by role)
• Policy acknowledgement records (where used)
• Screenshots/exports showing documents published in the controlled repository and accessible to intended audiences

Operational proof (procedure execution)

• Samples of completed privacy reviews (tickets, checklists, sign-offs)
• Samples of third-party privacy/security reviews tied to onboarding
• Exception requests and approvals
• Evidence register mapping procedures to artifacts and locations

Common exam/audit questions and hangups

Questions you should prepare to answer

• “Show me your PT-1 policy and procedures and where they are stored.”
• “Who is accountable for keeping them current?”
• “Who received them? Prove dissemination to the roles you defined.”
• “Show records generated by your procedures over time.”
• “How do you ensure third parties follow privacy requirements when they process data?”

Hangups that cause findings

• “Disseminated” is asserted but not proven (no training, no access logs, no attestations).
• Procedures exist but do not match reality (teams use Jira/ServiceNow, but procedures reference email).
• Documents are scattered and inconsistent (multiple “policies” with conflicting requirements).

Frequent implementation mistakes (and how to avoid them)

1. Writing a policy that is really a procedure.
   Fix: keep policy high-level; move steps, forms, and workflow specifics into procedures.

2. No defined audience for dissemination.
   Fix: define audience groups explicitly and tie them to training/acknowledgement expectations.

3. Evidence is ad hoc.
   Fix: create a PT-1 evidence register with named artifact owners and storage locations; update it when tools change.

4. Procedures don’t cover third parties.
   Fix: include procurement and third-party onboarding as first-class procedures. Privacy obligations frequently break at the boundary.

5. No governance for updates.
   Fix: establish document change control and a review trigger tied to material changes (new systems, new data uses, new third parties).

Enforcement context and risk implications

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

Operationally, PT-1 weaknesses tend to translate into two real risks:

• Assessment risk: you cannot demonstrate a functioning privacy program because PT-1 is the entry point for proving intent, execution, and dissemination. ²
• Control failure chaining: unclear procedures lead to inconsistent third-party onboarding, inconsistent privacy reviews, and gaps in retention/deletion. Those gaps surface during incidents and investigations.

Practical 30/60/90-day execution plan

This plan avoids dated timelines you cannot support with evidence; treat it as an execution sequence you can run quickly.

First 30 days (stabilize and publish)

• Assign PT-1 owner and approvers; document the governance workflow.
• Inventory existing privacy-related documents; select one canonical privacy policy.
• Draft or normalize the minimum viable set of procedures (start with third-party onboarding and privacy review intake).
• Publish in a controlled repository; set permissions and “single source of truth.”

Days 31–60 (disseminate and connect to workflows)

• Define dissemination audiences by role; assign training/attestations where appropriate.
• Embed procedures into operational tooling (ticket templates, procurement intake forms, SDLC gates).
• Build the PT-1 evidence register; identify artifact owners and storage locations.

Days 61–90 (prove operation and make it repeatable)

• Pull operational samples from each procedure (completed tickets, approvals, logs) and store them in an audit-ready package.
• Run an internal mini-assessment: pick a recent third-party onboarding and trace it end-to-end against your procedure.
• Add PT-1 to your control calendar and set change triggers (system changes, new data uses, incidents).

If you need to reduce manual work, Daydream is a natural place to track PT-1 ownership, link procedures, and define recurring evidence artifacts so the audit packet assembles reliably each cycle. ¹

Frequently Asked Questions

What counts as “procedures” for PT-1?

Procedures are executable instructions that teams can follow, with inputs, steps, approvals, and outputs. A one-page narrative without workflow steps usually fails because it does not produce consistent records. ¹

Who is the right audience for “disseminate to” if the parameter is not specified?

Define the audience based on who performs privacy-impacting work in your environment, then document it in your implementation statement and prove distribution to those groups. Keep it role-based so it survives org changes. ¹

Do I need workforce-wide policy acknowledgement?

If you require acknowledgement, keep the evidence. If you use training instead, retain completion records and show that training content references the policy and key procedures for relevant roles. ¹

How do I make PT-1 defensible for third-party risk management?

Add a third-party onboarding procedure that includes privacy review gates, contract requirements, and recordkeeping. Retain due diligence artifacts and approvals that show the procedure is consistently followed. ²

How detailed should the privacy policy be?

Keep the policy stable and testable: scope, responsibilities, and high-level requirements. Put operational detail into procedures so you can update workflows without rewriting policy language. ²

What is the fastest way to become audit-ready for PT-1?

Focus on traceability: map PT-1 to an owner, link the canonical policy and procedures, and define the recurring evidence artifacts you will produce. Then collect a small set of real operational samples that match your procedures. ¹

Footnotes

1. NIST SP 800-53 Rev. 5 OSCAL JSON

2. NIST SP 800-53 Rev. 5