A.17 ABC Inc. InfoSec Policy Exception Form

Requestor's Name :

Requestor's Phone Number:

Date:

Policy for which Exception is being requested :

A brief description of the justification for the request, including the organizations that would benefit from the exception:

Compensating procedures to be implemented to mitigate risk:

A technical description of the situation that is to exist after grant of the exception:

A risk analysis, including the organizations that might be put at risk by the exception:

The organizations responsible for implementing the exception

Requestor____________________________

Signature____________________________

Date _______________________________

CIO________________________________

Signature ____________________________

Date________________________________

CSO________________________________

Signature ____________________________

Date________________________________