Attach 4 PIAs

Attachment 4
Privacy Impact Assessments (PIAs)

NIH NCI California Health Interview Survey (CHIS)
Information Technology System – Page 1

NIH NCI California Health Interview Survey Cancer
Control Module (CHIS-CCM) 2009 – Page 17

06.1 HHS Privacy Impact Assessment (Form) / NIH NCI California Health
Interview Survey (CHIS) Information Technology System (Item)

Primavera
ProSight

Form Report, printed by: Milliard, Suzanne, Oct 5, 2010
PIA SUMMARY
1
The following required questions with an asterisk (*) represent the information necessary to complete the PIA Summary for transmission to the Office of
Management and Budget (OMB) and public posting in accordance with OMB Memorandum (M) 03-22.
Note: If a question or its response is not applicable, please answer “N/A” to that question where possible. If the system hosts a website, the Website Hosting
Practices section is required to be completed regardless of the presence of personally identifiable information (PII). If no PII is contained in the system,
please answer questions in the PIA Summary Tab and then promote the PIA to the Senior Official for Privacy who will authorize the PIA. If this system
contains PII, all remaining questions on the PIA Form Tabs must be completed prior to signature and promotion.

2

Summary of PIA Required Questions

*Is this a new PIA?

No
If this is an existing PIA, please provide a reason for revision:

PIA Validation
*1. Date of this Submission:

Jul 30, 2010
*2. OPDIV Name:

NIH
*4. Privacy Act System of Records Notice (SORN) Number (If response to Q.21 is Yes, a SORN number is required for Q.4):

N/A
*5. OMB Information Collection Approval Number:

0925-0598
*6. Other Identifying Number(s):

N02-PC-54400
*7. System Name (Align with system item name):

California Health Interview Survey (CHIS) Information Technology System
*9. System Point of Contact (POC). The System POC is the person to whom questions about the system and the responses to this PIA may be addressed:

Point of Contact Information
POC Name

Nancy Breen - NCI /Sansan Lin - UCLA

*10. Provide an overview of the system:

The California Health Interview Survey (CHIS) is a population-based random-digit dial telephone survey of California's population
conducted every other year since 2001 by the UCLA Center for Health Policy Research (UCLA-CHPR). UCLA-CHPR has the lead
responsibility of managing the survey, preparing, maintaining, and disseminating the CHIS data files, reporting the survey findings, and
disseminating the survey results. All CHIS confidential data files are maintained at the Data Access Center (DAC). No PII is contained
with the CHIS confidential data files. The Data Access Center is designed to provide access to CHIS confidential files in a secured,
controlled environment that protects the confidentiality of respondents.
*13. Indicate if the system is new or an existing one being modified:

New
*17. Does/Will the system collect, maintain (store), disseminate and/or pass through PII within any database(s), record(s), file(s) or website(s) hosted by this
system?
TIP: If the answer to Question 17 is “No” (indicating the system does not contain PII), only the remaining PIA Summary tab questions need to be completed
and submitted. If the system does contain PII, the full PIA must be completed and submitted. (Although note that “Employee systems,” – i.e., systems that

Attachment 4 – Page 1

collect PII “permitting the physical or online contacting of a specific individual … employed [by] the Federal Government – only need to complete the PIA
Summary tab.)

No
17a. Is this a GSS PIA included for C&A purposes only, with no ownership of underlying application data? If the response to Q.17a is Yes, the response to
Q.17 should be No and only the PIA Summary must be completed.

*19. Are records on the system retrieved by 1 or more PII data elements?

No
*21. Is the system subject to the Privacy Act? (If the response to Q.19 is Yes, the response to Q.21 must be Yes and a SORN number is required for Q.4)

No
*23. If the system shares or discloses PII, please specify with whom and for what purpose(s):

No PII in the system.
*30. Please describe in detail: (1) The information the agency will collect, maintain, or disseminate (clearly state if the information contained in the system
ONLY represents federal contact data); (2) Why and for what purpose the agency will use the information; (3) Explicitly indicate whether the information
contains PII; and (4) Whether submission of personal information is voluntary or mandatory:

All data received by UCLA-CHPR is in the de-identified form with all personal identiers removed. All research participants provide verbal
consent to participate in CHIS. The verbal consent script for each CHIS survey is approved by the UCLA Institutional Review Board and
the California Health & Human Services Committee for the Protection of Human Services. The consent script informs respondents about
the voluntary and confidential nature of the survey and assures them that their individual answers would not be linked to their identity or
disclosed. There is no PII in the system. All data is given voluntarily by respondents.
*31. Please describe in detail any processes in place to: (1) Notify and obtain consent from the individuals whose PII is in the system when major changes
occur to the system (e.g., disclosure and/or data uses have changed since the notice at the time of the original collection); (2) Notify and obtain consent from
individuals regarding what PII is being collected from them; and (3) How the information will be used or shared. (Note: Please describe in what format
individuals will be given notice of consent [e.g., written notice, electronic notice, etc.]):

No PII in the system.
*32. Does the system host a website? (Note: If the system hosts a website, the Website Hosting Practices section is required to be completed regardless of
the presence of PII)

No
*37. Does the website have any information or pages directed at children under the age of thirteen?

Not Applicable
*50. Are there policies or guidelines in place with regard to the retention and destruction of PII? (Refer to the C&A package and/or the Records Retention and
Destruction section in SORN)

Not Applicable
*54. Briefly describe in detail how the PII will be secured on the system using administrative, technical, and physical controls:

No PII in the system.

Attachment 4 – Page 2

PIA REQUIRE INFORMATION
1

HHS Privacy Impact Assessment (PIA)

The PIA determines if Personally Identifiable Information (PII) is contained within a system, what kind of PII, what is done with that information, and how that
information is protected. Systems with PII are subject to an extensive list of requirements based on privacy laws, regulations, and guidance. The HHS Privacy
Act Officer may be contacted for issues related to Freedom of Information Act (FOIA) and the Privacy Act. Respective Operating Division (OPDIV) Privacy
Contacts may be contacted for issues related to the Privacy Act. The Office of the Chief Information Officer (OCIO) can be used as a resource for questions
related to the administrative, technical, and physical controls of the system. Please note that answers to questions with an asterisk (*) will be submitted to the
Office of Management and Budget (OMB) and made publicly available in accordance with OMB Memorandum (M) 03-22.
Note: If a question or its response is not applicable, please answer “N/A” to that question where possible.

2

General Information

*Is this a new PIA?

No
If this is an existing PIA, please provide a reason for revision:

PIA Validation
*1. Date of this Submission:

Jul 30, 2010
*2. OPDIV Name:

NIH
3. Unique Project Identifier (UPI) Number for current fiscal year (Data is auto-populated from the System Inventory form, UPI table):

*4. Privacy Act System of Records Notice (SORN) Number (If response to Q.21 is Yes, a SORN number is required for Q.4):

N/A
*5. OMB Information Collection Approval Number:

0925-0598
5a. OMB Collection Approval Number Expiration Date:

Feb 28, 2011
*6. Other Identifying Number(s):

N02-PC-54400
*7. System Name: (Align with system item name)

California Health Interview Survey (CHIS) Information Technology System
8. System Location: (OPDIV or contractor office building, room, city, and state)

System Location:
OPDIV or contractor office building

UCLA Center for Health Policy Research, 10960 Wilshire Blvd.

Room

Suite 1550

City

Los Angeles

State

California

*9. System Point of Contact (POC). The System POC is the person to whom questions about the system and the responses to this PIA may be addressed:

Point of Contact Information
POC Name

Nancy Breen - NCI /Sansan Lin - UCLA

The following information will not be made publicly available:

Attachment 4 – Page 3

POC Title

Health Research Privacy Compliance Coordinator

POC Organization

UCLA Center for Health Policy Research

POC Phone

310-794-8362

POC Email

sslin@ucla.edu

*10. Provide an overview of the system: (Note: The System Inventory form can provide additional information for child dependencies if the system is a GSS)

The California Health Interview Survey (CHIS) is a population-based random-digit dial telephone survey of California's population
conducted every other year since 2001 by the UCLA Center for Health Policy Research (UCLA-CHPR). UCLA-CHPR has the lead
responsibility of managing the survey, preparing, maintaining, and disseminating the CHIS data files, reporting the survey findings, and
disseminating the survey results. All CHIS confidential data files are maintained at the Data Access Center (DAC). No PII is contained
with the CHIS confidential data files. The Data Access Center is designed to provide access to CHIS confidential files in a secured,
controlled environment that protects the confidentiality of respondents.

Attachment 4 – Page 4

SYSTEM CHARACTERIZATION AND DATA CATEGORIZATION
1

System Characterization and Data Configuration

11. Does HHS own the system?

11a. If no, identify the system owner:

12. Does HHS operate the system? (If the system is operated at a contractor site, the answer should be No)

12a. If no, identify the system operator:

*13. Indicate if the system is new or an existing one being modified:

New
14. Identify the life-cycle phase of this system:

15. Have any of the following major changes occurred to the system since the PIA was last submitted?

Please indicate “Yes” or “No” for each category below:

Yes/No

Conversions
Anonymous to Non-Anonymous
Significant System Management Changes
Significant Merging
New Public Access
Commercial Sources
New Interagency Uses
Internal Flow or Collection
Alteration in Character of Data

16. Is the system a General Support System (GSS), Major Application (MA), Minor Application (child) or Minor Application (stand-alone)?

Minor Application (child)
*17. Does/Will the system collect, maintain (store), disseminate and/or pass through PII within any database(s), record(s), file(s) or website(s) hosted by this
system?

No
TIP: If the answer to Question 17 is “No” (indicating the system does not contain PII), only the remaining PIA Summary tab questions need to be completed
and submitted. If the system does contain PII, the full PIA must be completed and submitted. (Although note that “Employee systems,” – i.e., systems that
collect PII “permitting the physical or online contacting of a specific individual … employed [by] the Federal Government – only need to complete the PIA
Summary tab.)
Please indicate "Yes" or "No" for each PII category. If the applicable PII category is not listed, please use the Other field to identify the appropriate category
of PII.

Categories:

Yes/No

Name (for purposes other than contacting federal
employees)

Attachment 4 – Page 5

Date of Birth
Social Security Number (SSN)
Photographic Identifiers
Driver’s License
Biometric Identifiers
Mother’s Maiden Name
Vehicle Identifiers
Personal Mailing Address
Personal Phone Numbers
Medical Records Numbers
Medical Notes
Financial Account Information
Certificates
Legal Documents
Device Identifiers
Web Uniform Resource Locator(s) (URL)
Personal Email Address
Education Records
Military Status
Employment Status
Foreign Activities
Other

17a. Is this a GSS PIA included for C&A purposes only, with no ownership of underlying application data? If the response to Q.17a is Yes, the response to
Q.17 should be No and only the PIA Summary must be completed.

18. Please indicate the categories of individuals about whom PII is collected, maintained, disseminated and/or passed through. Note: If the applicable PII
category is not listed, please use the Other field to identify the appropriate category of PII. Please answer "Yes" or "No" to each of these choices (NA in other
is not applicable).

Categories:

Yes/No

Employees
Public Citizen
Patients
Business partners/contacts (Federal, state, local
agencies)
Vendors/Suppliers/Contractors
Other

*19. Are records on the system retrieved by 1 or more PII data elements?

No

Attachment 4 – Page 6

Please indicate "Yes" or "No" for each PII category. If the applicable PII category is not listed, please use the Other field to identify the appropriate category
of PII.

Categories:

Yes/No

Name (for purposes other than contacting federal
employees)
Date of Birth
SSN
Photographic Identifiers
Driver’s License
Biometric Identifiers
Mother’s Maiden Name
Vehicle Identifiers
Personal Mailing Address
Personal Phone Numbers
Medical Records Numbers
Medical Notes
Financial Account Information
Certificates
Legal Documents
Device Identifiers
Web URLs
Personal Email Address
Education Records
Military Status
Employment Status
Foreign Activities
Other

20. Are 10 or more records containing PII maintained, stored or transmitted/passed through this system?

*21. Is the system subject to the Privacy Act? (If the response to Q.19 is Yes, the response to Q.21 must be Yes and a SORN number is required for Q.4)

No
21a. If yes but a SORN has not been created, please provide an explanation.

Attachment 4 – Page 7

INFORMATION SHARING PRACTICES
1

Information Sharing Practices

22. Does the system share or disclose PII with other divisions within this agency, external agencies, or other people or organizations outside the agency?

Please indicate “Yes” or “No” for each category below:

Yes/No

Name (for purposes other than contacting federal
employees)
Date of Birth
SSN
Photographic Identifiers
Driver’s License
Biometric Identifiers
Mother’s Maiden Name
Vehicle Identifiers
Personal Mailing Address
Personal Phone Numbers
Medical Records Numbers
Medical Notes
Financial Account Information
Certificates
Legal Documents
Device Identifiers
Web URLs
Personal Email Address
Education Records
Military Status
Employment Status
Foreign Activities
Other

*23. If the system shares or discloses PII please specify with whom and for what purpose(s):

No PII in the system.
24. If the PII in the system is matched against PII in one or more other computer systems, are computer data matching agreement(s) in place?

25. Is there a process in place to notify organizations or systems that are dependent upon the PII contained in this system when major changes occur (i.e.,
revisions to PII, or when the system is replaced)?

26. Are individuals notified how their PII is going to be used?

Attachment 4 – Page 8

26a. If yes, please describe the process for allowing individuals to have a choice. If no, please provide an explanation.

27. Is there a complaint process in place for individuals who believe their PII has been inappropriately obtained, used, or disclosed, or that the PII is
inaccurate?

27a. If yes, please describe briefly the notification process. If no, please provide an explanation.

28. Are there processes in place for periodic reviews of PII contained in the system to ensure the data’s integrity, availability, accuracy and relevancy?

28a. If yes, please describe briefly the review process. If no, please provide an explanation.

29. Are there rules of conduct in place for access to PII on the system?

Please indicate "Yes," "No," or "N/A" for each category. If yes, briefly state the purpose for each user to have access:

Users with access to PII

Yes/No/N/A

Purpose

User
Administrators
Developers
Contractors
Other

*30. Please describe in detail: (1) The information the agency will collect, maintain, or disseminate (clearly state if the information contained in the system
ONLY represents federal contact data); (2) Why and for what purpose the agency will use the information; (3) Explicitly indicate whether the information
contains PII; and (4) Whether submission of personal information is voluntary or mandatory:

All data received by UCLA-CHPR is in the de-identified form with all personal identiers removed. All research participants provide verbal
consent to participate in CHIS. The verbal consent script for each CHIS survey is approved by the UCLA Institutional Review Board and
the California Health & Human Services Committee for the Protection of Human Services. The consent script informs respondents about
the voluntary and confidential nature of the survey and assures them that their individual answers would not be linked to their identity or
disclosed. There is no PII in the system. All data is given voluntarily by respondents.
*31. Please describe in detail any processes in place to: (1) Notify and obtain consent from the individuals whose PII is in the system when major changes
occur to the system (e.g., disclosure and/or data uses have changed since the notice at the time of the original collection); (2) Notify and obtain consent from
individuals regarding what PII is being collected from them; and (3) How the information will be used or shared. (Note: Please describe in what format
individuals will be given notice of consent [e.g., written notice, electronic notice, etc.])

No PII in the system.

Attachment 4 – Page 9

WEBSITE HOSTING PRACTICES
1

Website Hosting Practices

*32. Does the system host a website? (Note: If the system hosts a website, the Website Hosting Practices section is required to be completed regardless of
the presence of PII)

No

Please indicate “Yes” or “No” for each Yes/ No
type of site below. If the system hosts
both Internet and Intranet sites,
indicate “Yes” for “Both” only.

If the system hosts an Internet site,
please enter the site URL. Do not
enter any URL(s) for Intranet sites.

Internet
Intranet
Both

33. Does the system host a website that is accessible by the public and does not meet the exceptions listed in OMB M-03-22?
Note: OMB M-03-22 Attachment A, Section III, Subsection C requires agencies to post a privacy policy for websites that are accessible to the public, but
provides three exceptions: (1) Websites containing information other than "government information" as defined in OMB Circular A-130; (2) Agency intranet
websites that are accessible only by authorized government users (employees, contractors, consultants, fellows, grantees); and (3) National security systems
defined at 40 U.S.C. 11103 as exempt from the definition of information technology (see section 202(i) of the E-Government Act.).

34. If the website does not meet one or more of the exceptions described in Q. 33 (i.e., response to Q. 33 is "Yes"), a website privacy policy statement
(consistent with OMB M-03-22 and Title II and III of the E-Government Act) is required. Has a website privacy policy been posted?

35. If a website privacy policy is required (i.e., response to Q. 34 is “Yes”), is the privacy policy in machine-readable format, such as Platform for Privacy
Preferences (P3P)?

35a. If no, please indicate when the website will be P3P compliant:

36. Does the website employ tracking technologies?

Please indicate “Yes”, “No”, or “N/A” for each type of
cookie below:

Yes/No/N/A

Web Bugs
Web Beacons
Session Cookies
Persistent Cookies
Other

*37. Does the website have any information or pages directed at children under the age of thirteen?

Not Applicable
37a. If yes, is there a unique privacy policy for the site, and does the unique privacy policy address the process for obtaining parental consent if any
information is collected?

38. Does the website collect PII from individuals?

Attachment 4 – Page 10

Please indicate “Yes” or “No” for each category below:

Yes/No

Name (for purposes other than contacting federal
employees)
Date of Birth
SSN
Photographic Identifiers
Driver's License
Biometric Identifiers
Mother's Maiden Name
Vehicle Identifiers
Personal Mailing Address
Personal Phone Numbers
Medical Records Numbers
Medical Notes
Financial Account Information
Certificates
Legal Documents
Device Identifiers
Web URLs
Personal Email Address
Education Records
Military Status
Employment Status
Foreign Activities
Other

39. Are rules of conduct in place for access to PII on the website?

40. Does the website contain links to sites external to HHS that owns and/or operates the system?

40a. If yes, note whether the system provides a disclaimer notice for users that follow external links to websites not owned or operated by HHS.

Attachment 4 – Page 11

ADMINISTRATIVE CONTROLS
1

Administrative Controls

Note: This PIA uses the terms “Administrative,” “Technical” and “Physical” to refer to security control questions—terms that are used in several Federal
laws when referencing security requirements.
41. Has the system been certified and accredited (C&A)?

41a. If yes, please indicate when the C&A was completed (Note: The C&A date is populated in the System Inventory form via the responsible Security
personnel):

41b. If a system requires a C&A and no C&A was completed, is a C&A in progress?

42. Is there a system security plan for this system?

43. Is there a contingency (or backup) plan for the system?

44. Are files backed up regularly?

45. Are backup files stored offsite?

46. Are there user manuals for the system?

47. Have personnel (system owners, managers, operators, contractors and/or program managers) using the system been trained and made aware of their
responsibilities for protecting the information being collected and maintained?

48. If contractors operate or use the system, do the contracts include clauses ensuring adherence to privacy provisions and practices?

49. Are methods in place to ensure least privilege (i.e., “need to know” and accountability)?

49a. If yes, please specify method(s):

*50. Are there policies or guidelines in place with regard to the retention and destruction of PII? (Refer to the C&A package and/or the Records Retention
and Destruction section in SORN):

Not Applicable
50a. If yes, please provide some detail about these policies/practices:

Attachment 4 – Page 12

TECHNICAL CONTROLS
1

Technical Controls

51. Are technical controls in place to minimize the possibility of unauthorized access, use, or dissemination of the data in the system?

Please indicate “Yes” or “No” for each category below:

Yes/No

User Identification
Passwords
Firewall
Virtual Private Network (VPN)
Encryption
Intrusion Detection System (IDS)
Common Access Cards (CAC)
Smart Cards
Biometrics
Public Key Infrastructure (PKI)

52. Is there a process in place to monitor and respond to privacy and/or security incidents?

52a. If yes, please briefly describe the process:

Attachment 4 – Page 13

PHYSICAL ACCESS
1

Physical Access

53. Are physical access controls in place?

Please indicate “Yes” or “No” for each category below:

Yes/No

Guards
Identification Badges
Key Cards
Cipher Locks
Biometrics
Closed Circuit TV (CCTV)

*54. Briefly describe in detail how the PII will be secured on the system using administrative, technical, and physical controls:

No PII in the system.

Attachment 4 – Page 14

APPROVAL/DEMOTION
1

System Information

System Name:

2

California Health Interview Survey (CHIS) Information Technology System

PIA Reviewer Approval/Promotion or Demotion

Promotion/Demotion:

Promote

Comments:
Approval/Demotion Point
of Contact:

Suzy Milliard

Date:

Jul 30, 2010

3

Senior Official for Privacy Approval/Promotion or Demotion

Promotion/Demotion:

Promote

Comments:

4

OPDIV Senior Official for Privacy or Designee Approval

Please print the PIA and obtain the endorsement of the reviewing official below. Once the signature has been collected,
retain a hard copy for the OPDIV's records. Submitting the PIA will indicate the reviewing official has endorsed it
This PIA has been reviewed and endorsed by the OPDIV Senior Official for Privacy or Designee (Name and Date):
Name: __________________________________

Date: ________________________________________

Name:

Karen Plá

Date:

5

Sep 28, 2010

Department Approval to Publish to the Web

Approved for web publishing
Date Published:

Yes
Sep 1, 2009

Publicly posted PIA URL or no PIA URL explanation:

Attachment 4 – Page 15

PIA % COMPLETE
1

PIA Completion

PIA Percentage Complete:

100.00

PIA Missing Fields:

Attachment 4 – Page 16

06.1 HHS Privacy Impact Assessment (Form) / NIH NCI California Health
Interview Survey Cancer Control Module (CHIS-CCM) 2009 (Item)

Primavera
ProSight

Form Report, printed by: Milliard, Suzanne, Oct 5, 2010
PIA SUMMARY
1
The following required questions with an asterisk (*) represent the information necessary to complete the PIA Summary for transmission to the Office of
Management and Budget (OMB) and public posting in accordance with OMB Memorandum (M) 03-22.
Note: If a question or its response is not applicable, please answer “N/A” to that question where possible. If the system hosts a website, the Website Hosting
Practices section is required to be completed regardless of the presence of personally identifiable information (PII). If no PII is contained in the system,
please answer questions in the PIA Summary Tab and then promote the PIA to the Senior Official for Privacy who will authorize the PIA. If this system
contains PII, all remaining questions on the PIA Form Tabs must be completed prior to signature and promotion.

2

Summary of PIA Required Questions

*Is this a new PIA?

No
If this is an existing PIA, please provide a reason for revision:

PIA Validation
*1. Date of this Submission:

Jul 30, 2010
*2. OPDIV Name:

NIH
*4. Privacy Act System of Records Notice (SORN) Number (If response to Q.21 is Yes, a SORN number is required for Q.4):

N/A
*5. OMB Information Collection Approval Number:

0925-0598
*6. Other Identifying Number(s):

N02-PC-54400
*7. System Name (Align with system item name):

NIH NCI California Health Interview Survey Cancer Control Module (CHIS-CCM) 2009
*9. System Point of Contact (POC). The System POC is the person to whom questions about the system and the responses to this PIA may be addressed:

Point of Contact Information
POC Name

Nancy Breen

*10. Provide an overview of the system:

IMS is contracted by NCI to maintain CHIS microdata in a secure environment. There is no identifying information in the data. CHIS data
include a range of cancer control variables for respondents including use of cancer screening, and a wide range of socio-demographic
variables including health insurance status, usual source of health care. NCI analysts examine statistical patterns and trends in cancer
control outcomes in California using CHIS. IMS staff develop programs to conduct statistical analyses as specified by NCI researchers.
*13. Indicate if the system is new or an existing one being modified:

Existing
*17. Does/Will the system collect, maintain (store), disseminate and/or pass through PII within any database(s), record(s), file(s) or website(s) hosted by this
system?
TIP: If the answer to Question 17 is “No” (indicating the system does not contain PII), only the remaining PIA Summary tab questions need to be completed
and submitted. If the system does contain PII, the full PIA must be completed and submitted. (Although note that “Employee systems,” – i.e., systems that
collect PII “permitting the physical or online contacting of a specific individual … employed [by] the Federal Government – only need to complete the PIA
Summary tab.)

Attachment 4 – Page 17

No
17a. Is this a GSS PIA included for C&A purposes only, with no ownership of underlying application data? If the response to Q.17a is Yes, the response to
Q.17 should be No and only the PIA Summary must be completed.

*19. Are records on the system retrieved by 1 or more PII data elements?

No
*21. Is the system subject to the Privacy Act? (If the response to Q.19 is Yes, the response to Q.21 must be Yes and a SORN number is required for Q.4)

No
*23. If the system shares or discloses PII, please specify with whom and for what purpose(s):

N/A
*30. Please describe in detail: (1) The information the agency will collect, maintain, or disseminate (clearly state if the information contained in the system
ONLY represents federal contact data); (2) Why and for what purpose the agency will use the information; (3) Explicitly indicate whether the information
contains PII; and (4) Whether submission of personal information is voluntary or mandatory:

1) IMS is under contract with NCI to maintain CHIS microdata files as needed for analysis by NCI. IMS programers and statisticians work
under contract with NCI staff to help with programming and statistical analysis as specified by NCI staff. 2) NCI uses CHIS data to
conduct statistical analysis of cancer control outcomes. These include use of cancer screening services, patterns and trends in tobacco
use, physical activity and other cancer-control related behaviors. 3) No PII in the system. 4) No PII in the system.
*31. Please describe in detail any processes in place to: (1) Notify and obtain consent from the individuals whose PII is in the system when major changes
occur to the system (e.g., disclosure and/or data uses have changed since the notice at the time of the original collection); (2) Notify and obtain consent from
individuals regarding what PII is being collected from them; and (3) How the information will be used or shared. (Note: Please describe in what format
individuals will be given notice of consent [e.g., written notice, electronic notice, etc.]):

No PII in the system.
*32. Does the system host a website? (Note: If the system hosts a website, the Website Hosting Practices section is required to be completed regardless of
the presence of PII)

No
*37. Does the website have any information or pages directed at children under the age of thirteen?

No
*50. Are there policies or guidelines in place with regard to the retention and destruction of PII? (Refer to the C&A package and/or the Records Retention and
Destruction section in SORN)

Not Applicable
*54. Briefly describe in detail how the PII will be secured on the system using administrative, technical, and physical controls:

No PII in the system.

Attachment 4 – Page 18

PIA REQUIRE INFORMATION
1

HHS Privacy Impact Assessment (PIA)

The PIA determines if Personally Identifiable Information (PII) is contained within a system, what kind of PII, what is done with that information, and how that
information is protected. Systems with PII are subject to an extensive list of requirements based on privacy laws, regulations, and guidance. The HHS Privacy
Act Officer may be contacted for issues related to Freedom of Information Act (FOIA) and the Privacy Act. Respective Operating Division (OPDIV) Privacy
Contacts may be contacted for issues related to the Privacy Act. The Office of the Chief Information Officer (OCIO) can be used as a resource for questions
related to the administrative, technical, and physical controls of the system. Please note that answers to questions with an asterisk (*) will be submitted to the
Office of Management and Budget (OMB) and made publicly available in accordance with OMB Memorandum (M) 03-22.
Note: If a question or its response is not applicable, please answer “N/A” to that question where possible.

2

General Information

*Is this a new PIA?

No
If this is an existing PIA, please provide a reason for revision:

PIA Validation
*1. Date of this Submission:

Jul 30, 2010
*2. OPDIV Name:

NIH
3. Unique Project Identifier (UPI) Number for current fiscal year (Data is auto-populated from the System Inventory form, UPI table):

*4. Privacy Act System of Records Notice (SORN) Number (If response to Q.21 is Yes, a SORN number is required for Q.4):

N/A
*5. OMB Information Collection Approval Number:

0925-0598
5a. OMB Collection Approval Number Expiration Date:

Feb 28, 2011
*6. Other Identifying Number(s):

N02-PC-54400
*7. System Name: (Align with system item name)

NIH NCI California Health Interview Survey Cancer Control Module (CHIS-CCM) 2009
8. System Location: (OPDIV or contractor office building, room, city, and state)

System Location:
OPDIV or contractor office building

12501 Prosperity Drive

Room

Suite 200 - Server Room

City

Silver Spring

State

MD

*9. System Point of Contact (POC). The System POC is the person to whom questions about the system and the responses to this PIA may be addressed:

Point of Contact Information
POC Name

Nancy Breen

The following information will not be made publicly available:

Attachment 4 – Page 19

POC Title

Project Officer

POC Organization

NCI/DCCPS/ARP/HSEB

POC Phone

301-496-4675

POC Email

breenn@mail.nih.gov

*10. Provide an overview of the system: (Note: The System Inventory form can provide additional information for child dependencies if the system is a GSS)

IMS is contracted by NCI to maintain CHIS microdata in a secure environment. There is no identifying information in the data. CHIS data
include a range of cancer control variables for respondents including use of cancer screening, and a wide range of socio-demographic
variables including health insurance status, usual source of health care. NCI analysts examine statistical patterns and trends in cancer
control outcomes in California using CHIS. IMS staff develop programs to conduct statistical analyses as specified by NCI researchers.

Attachment 4 – Page 20

SYSTEM CHARACTERIZATION AND DATA CATEGORIZATION
1

System Characterization and Data Configuration

11. Does HHS own the system?

11a. If no, identify the system owner:

12. Does HHS operate the system? (If the system is operated at a contractor site, the answer should be No)

12a. If no, identify the system operator:

*13. Indicate if the system is new or an existing one being modified:

Existing
14. Identify the life-cycle phase of this system:

15. Have any of the following major changes occurred to the system since the PIA was last submitted?

Please indicate “Yes” or “No” for each category below:

Yes/No

Conversions
Anonymous to Non-Anonymous
Significant System Management Changes
Significant Merging
New Public Access
Commercial Sources
New Interagency Uses
Internal Flow or Collection
Alteration in Character of Data

16. Is the system a General Support System (GSS), Major Application (MA), Minor Application (child) or Minor Application (stand-alone)?

Minor Application (child)
*17. Does/Will the system collect, maintain (store), disseminate and/or pass through PII within any database(s), record(s), file(s) or website(s) hosted by this
system?

No
TIP: If the answer to Question 17 is “No” (indicating the system does not contain PII), only the remaining PIA Summary tab questions need to be completed
and submitted. If the system does contain PII, the full PIA must be completed and submitted. (Although note that “Employee systems,” – i.e., systems that
collect PII “permitting the physical or online contacting of a specific individual … employed [by] the Federal Government – only need to complete the PIA
Summary tab.)
Please indicate "Yes" or "No" for each PII category. If the applicable PII category is not listed, please use the Other field to identify the appropriate category
of PII.

Categories:

Yes/No

Name (for purposes other than contacting federal
employees)

Attachment 4 – Page 21

Date of Birth
Social Security Number (SSN)
Photographic Identifiers
Driver’s License
Biometric Identifiers
Mother’s Maiden Name
Vehicle Identifiers
Personal Mailing Address
Personal Phone Numbers
Medical Records Numbers
Medical Notes
Financial Account Information
Certificates
Legal Documents
Device Identifiers
Web Uniform Resource Locator(s) (URL)
Personal Email Address
Education Records
Military Status
Employment Status
Foreign Activities
Other

17a. Is this a GSS PIA included for C&A purposes only, with no ownership of underlying application data? If the response to Q.17a is Yes, the response to
Q.17 should be No and only the PIA Summary must be completed.

18. Please indicate the categories of individuals about whom PII is collected, maintained, disseminated and/or passed through. Note: If the applicable PII
category is not listed, please use the Other field to identify the appropriate category of PII. Please answer "Yes" or "No" to each of these choices (NA in other
is not applicable).

Categories:

Yes/No

Employees
Public Citizen
Patients
Business partners/contacts (Federal, state, local
agencies)
Vendors/Suppliers/Contractors
Other

*19. Are records on the system retrieved by 1 or more PII data elements?

No

Attachment 4 – Page 22

Please indicate "Yes" or "No" for each PII category. If the applicable PII category is not listed, please use the Other field to identify the appropriate category
of PII.

Categories:

Yes/No

Name (for purposes other than contacting federal
employees)
Date of Birth
SSN
Photographic Identifiers
Driver’s License
Biometric Identifiers
Mother’s Maiden Name
Vehicle Identifiers
Personal Mailing Address
Personal Phone Numbers
Medical Records Numbers
Medical Notes
Financial Account Information
Certificates
Legal Documents
Device Identifiers
Web URLs
Personal Email Address
Education Records
Military Status
Employment Status
Foreign Activities
Other

20. Are 10 or more records containing PII maintained, stored or transmitted/passed through this system?

*21. Is the system subject to the Privacy Act? (If the response to Q.19 is Yes, the response to Q.21 must be Yes and a SORN number is required for Q.4)

No
21a. If yes but a SORN has not been created, please provide an explanation.

Attachment 4 – Page 23

INFORMATION SHARING PRACTICES
1

Information Sharing Practices

22. Does the system share or disclose PII with other divisions within this agency, external agencies, or other people or organizations outside the agency?

Please indicate “Yes” or “No” for each category below:

Yes/No

Name (for purposes other than contacting federal
employees)
Date of Birth
SSN
Photographic Identifiers
Driver’s License
Biometric Identifiers
Mother’s Maiden Name
Vehicle Identifiers
Personal Mailing Address
Personal Phone Numbers
Medical Records Numbers
Medical Notes
Financial Account Information
Certificates
Legal Documents
Device Identifiers
Web URLs
Personal Email Address
Education Records
Military Status
Employment Status
Foreign Activities
Other

*23. If the system shares or discloses PII please specify with whom and for what purpose(s):

N/A
24. If the PII in the system is matched against PII in one or more other computer systems, are computer data matching agreement(s) in place?

25. Is there a process in place to notify organizations or systems that are dependent upon the PII contained in this system when major changes occur (i.e.,
revisions to PII, or when the system is replaced)?

26. Are individuals notified how their PII is going to be used?

Attachment 4 – Page 24

26a. If yes, please describe the process for allowing individuals to have a choice. If no, please provide an explanation.

27. Is there a complaint process in place for individuals who believe their PII has been inappropriately obtained, used, or disclosed, or that the PII is
inaccurate?

27a. If yes, please describe briefly the notification process. If no, please provide an explanation.

28. Are there processes in place for periodic reviews of PII contained in the system to ensure the data’s integrity, availability, accuracy and relevancy?

28a. If yes, please describe briefly the review process. If no, please provide an explanation.

29. Are there rules of conduct in place for access to PII on the system?

Please indicate "Yes," "No," or "N/A" for each category. If yes, briefly state the purpose for each user to have access:

Users with access to PII

Yes/No/N/A

Purpose

User
Administrators
Developers
Contractors
Other

*30. Please describe in detail: (1) The information the agency will collect, maintain, or disseminate (clearly state if the information contained in the system
ONLY represents federal contact data); (2) Why and for what purpose the agency will use the information; (3) Explicitly indicate whether the information
contains PII; and (4) Whether submission of personal information is voluntary or mandatory:

1) IMS is under contract with NCI to maintain CHIS microdata files as needed for analysis by NCI. IMS programers and statisticians work
under contract with NCI staff to help with programming and statistical analysis as specified by NCI staff. 2) NCI uses CHIS data to
conduct statistical analysis of cancer control outcomes. These include use of cancer screening services, patterns and trends in tobacco
use, physical activity and other cancer-control related behaviors. 3) No PII in the system. 4) No PII in the system.
*31. Please describe in detail any processes in place to: (1) Notify and obtain consent from the individuals whose PII is in the system when major changes
occur to the system (e.g., disclosure and/or data uses have changed since the notice at the time of the original collection); (2) Notify and obtain consent from
individuals regarding what PII is being collected from them; and (3) How the information will be used or shared. (Note: Please describe in what format
individuals will be given notice of consent [e.g., written notice, electronic notice, etc.])

No PII in the system.

Attachment 4 – Page 25

WEBSITE HOSTING PRACTICES
1

Website Hosting Practices

*32. Does the system host a website? (Note: If the system hosts a website, the Website Hosting Practices section is required to be completed regardless of
the presence of PII)

No

Please indicate “Yes” or “No” for each Yes/ No
type of site below. If the system hosts
both Internet and Intranet sites,
indicate “Yes” for “Both” only.

If the system hosts an Internet site,
please enter the site URL. Do not
enter any URL(s) for Intranet sites.

Internet
Intranet
Both

33. Does the system host a website that is accessible by the public and does not meet the exceptions listed in OMB M-03-22?
Note: OMB M-03-22 Attachment A, Section III, Subsection C requires agencies to post a privacy policy for websites that are accessible to the public, but
provides three exceptions: (1) Websites containing information other than "government information" as defined in OMB Circular A-130; (2) Agency intranet
websites that are accessible only by authorized government users (employees, contractors, consultants, fellows, grantees); and (3) National security systems
defined at 40 U.S.C. 11103 as exempt from the definition of information technology (see section 202(i) of the E-Government Act.).

34. If the website does not meet one or more of the exceptions described in Q. 33 (i.e., response to Q. 33 is "Yes"), a website privacy policy statement
(consistent with OMB M-03-22 and Title II and III of the E-Government Act) is required. Has a website privacy policy been posted?

35. If a website privacy policy is required (i.e., response to Q. 34 is “Yes”), is the privacy policy in machine-readable format, such as Platform for Privacy
Preferences (P3P)?

35a. If no, please indicate when the website will be P3P compliant:

36. Does the website employ tracking technologies?

Please indicate “Yes”, “No”, or “N/A” for each type of
cookie below:

Yes/No/N/A

Web Bugs
Web Beacons
Session Cookies
Persistent Cookies
Other

*37. Does the website have any information or pages directed at children under the age of thirteen?

No
37a. If yes, is there a unique privacy policy for the site, and does the unique privacy policy address the process for obtaining parental consent if any
information is collected?

38. Does the website collect PII from individuals?

Attachment 4 – Page 26

Please indicate “Yes” or “No” for each category below:

Yes/No

Name (for purposes other than contacting federal
employees)
Date of Birth
SSN
Photographic Identifiers
Driver's License
Biometric Identifiers
Mother's Maiden Name
Vehicle Identifiers
Personal Mailing Address
Personal Phone Numbers
Medical Records Numbers
Medical Notes
Financial Account Information
Certificates
Legal Documents
Device Identifiers
Web URLs
Personal Email Address
Education Records
Military Status
Employment Status
Foreign Activities
Other

39. Are rules of conduct in place for access to PII on the website?

40. Does the website contain links to sites external to HHS that owns and/or operates the system?

40a. If yes, note whether the system provides a disclaimer notice for users that follow external links to websites not owned or operated by HHS.

Attachment 4 – Page 27

ADMINISTRATIVE CONTROLS
1

Administrative Controls

Note: This PIA uses the terms “Administrative,” “Technical” and “Physical” to refer to security control questions—terms that are used in several Federal
laws when referencing security requirements.
41. Has the system been certified and accredited (C&A)?

41a. If yes, please indicate when the C&A was completed (Note: The C&A date is populated in the System Inventory form via the responsible Security
personnel):

41b. If a system requires a C&A and no C&A was completed, is a C&A in progress?

42. Is there a system security plan for this system?

43. Is there a contingency (or backup) plan for the system?

44. Are files backed up regularly?

45. Are backup files stored offsite?

46. Are there user manuals for the system?

47. Have personnel (system owners, managers, operators, contractors and/or program managers) using the system been trained and made aware of their
responsibilities for protecting the information being collected and maintained?

48. If contractors operate or use the system, do the contracts include clauses ensuring adherence to privacy provisions and practices?

49. Are methods in place to ensure least privilege (i.e., “need to know” and accountability)?

49a. If yes, please specify method(s):

*50. Are there policies or guidelines in place with regard to the retention and destruction of PII? (Refer to the C&A package and/or the Records Retention
and Destruction section in SORN):

Not Applicable
50a. If yes, please provide some detail about these policies/practices:

Attachment 4 – Page 28

TECHNICAL CONTROLS
1

Technical Controls

51. Are technical controls in place to minimize the possibility of unauthorized access, use, or dissemination of the data in the system?

Please indicate “Yes” or “No” for each category below:

Yes/No

User Identification
Passwords
Firewall
Virtual Private Network (VPN)
Encryption
Intrusion Detection System (IDS)
Common Access Cards (CAC)
Smart Cards
Biometrics
Public Key Infrastructure (PKI)

52. Is there a process in place to monitor and respond to privacy and/or security incidents?

52a. If yes, please briefly describe the process:

Attachment 4 – Page 29

PHYSICAL ACCESS
1

Physical Access

53. Are physical access controls in place?

Please indicate “Yes” or “No” for each category below:

Yes/No

Guards
Identification Badges
Key Cards
Cipher Locks
Biometrics
Closed Circuit TV (CCTV)

*54. Briefly describe in detail how the PII will be secured on the system using administrative, technical, and physical controls:

No PII in the system.

Attachment 4 – Page 30

APPROVAL/DEMOTION
1

System Information

System Name:

2

NIH NCI California Health Interview Survey Cancer Control Module (CHIS-CCM) 2009

PIA Reviewer Approval/Promotion or Demotion

Promotion/Demotion:

Promote

Comments:
Approval/Demotion Point
of Contact:

Suzy Milliard

Date:

Jul 30, 2010

3

Senior Official for Privacy Approval/Promotion or Demotion

Promotion/Demotion:

Promote

Comments:

4

OPDIV Senior Official for Privacy or Designee Approval

Please print the PIA and obtain the endorsement of the reviewing official below. Once the signature has been collected,
retain a hard copy for the OPDIV's records. Submitting the PIA will indicate the reviewing official has endorsed it
This PIA has been reviewed and endorsed by the OPDIV Senior Official for Privacy or Designee (Name and Date):
Name: __________________________________

Date: ________________________________________

Name:

Karen Plá

Date:

5

Sep 28, 2010

Department Approval to Publish to the Web

Approved for web publishing
Date Published:

Yes
Sep 1, 2009

Publicly posted PIA URL or no PIA URL explanation:

Attachment 4 – Page 31

PIA % COMPLETE
1

PIA Completion

PIA Percentage Complete:

100.00

PIA Missing Fields:

Attachment 4 – Page 32