Pta

The Privacy Office
U.S. Department of Homeland Security
Washington, DC 20528
703-235-0780, pia@dhs.gov
www.dhs.gov/privacy

Privacy Threshold Analysis
Version date: June 10th, 2009
Page 1 of 7

PRIVACY THRESHOLD ANALYSIS (PTA)
This form is used to determine whether
a Privacy Impact Assessment is required.

Please use the attached form to determine whether a Privacy Impact Assessment (PIA) is required under
the E-Government Act of 2002 and the Homeland Security Act of 2002.
Please complete this form and send it to your component Privacy Office. If you do not have a component
Privacy Office, please send the PTA to the DHS Privacy Office:
Rebecca J. Richards
Director of Privacy Compliance
The Privacy Office
U.S. Department of Homeland Security
Washington, DC 20528
Tel: 703-235-0780

PIA@dhs.gov

Upon receipt, the DHS Privacy Office will review this form. If a PIA is required, the DHS Privacy Office
will send you a copy of the Official Privacy Impact Assessment Guide and accompanying Template to
complete and return.
A copy of the Guide and Template is available on the DHS Privacy Office website, www.dhs.gov/privacy,
on DHSOnline and directly from the DHS Privacy Office via email: pia@dhs.gov, phone: 703-235-0780.

The Privacy Office
U.S. Department of Homeland Security
Washington, DC 20528
703-235-0780, pia@dhs.gov
www.dhs.gov/privacy

Privacy Threshold Analysis
Version date: June 10th, 2009
Page 2 of 7

PRIVACY THRESHOLD ANALYSIS (PTA)
Please complete this form and send it to the DHS Privacy Office.
Upon receipt, the DHS Privacy Office will review this form
and may request additional information.
SUMMARY INFORMATION
DATE submitted for review: February 23, 2010
NAME of Project: Form G-646, Sworn Statement of Refugee Applying for Admission into
the United States
Name of Component: US Citizenship and Immigration Services
Name of Project Manager: Essie L. Bell
Email for Project Manager: essie.bell@dhs.gov
Phone number for Project Manager: 202-272-8035
TYPE of Project:
Information Technology and/or System 
A Notice of Proposed Rule Making or a Final Ru le.
Other:

8.

Can the system be accessed remotely?
No.
Yes. When remote access is allowed, is the access accomplished by a virtual private network
(VPN)?
No.
Yes.

The Privacy Office
U.S. Department of Homeland Security
Washington, DC 20528
703-235-0780, pia@dhs.gov
www.dhs.gov/privacy

Privacy Threshold Analysis
Version date: June 10th, 2009
Page 6 of 7
9.

Is Personally Identifiable Information 2 physically transported outside of the LAN? (This can
include mobile devices, flash drives, laptops, etc.)
No.
Yes.

10.

Does the system connect, receive, or share Personally Identifiable Information with any other
DHS systems3?
No
Yes. Please list:

11.

Are there regular (ie. periodic, recurring, etc.) data extractions from the system?
No.
Yes. Are these extractions included as part of the Certification and Accreditation4?
Yes.
No.

12.

Is there a Certification & Accreditation record within OCIO’s FISMA tracking system?
Unknown.
No.
Yes. Please indicate the determinations for each of the following:

2

Confidentiality:

Low

Moderate

High

Undefined

Integrity:

Low

Moderate

High

Undefined

Availability:

Low

Moderate

High

Undefined

Personally Identifiable Information is information that can identify a person. This includes; name, address, phone
number, social security number, as well as health information or a physical description.
3
PII may be shared, received, or connected to other DHS systems directly, automatically, or by manual processes.
Often, these systems are listed as “interconnected systems” in TAFISMA.
4
This could include the Standard Operation Procedures (SOP) or a Memorandum of Understanding (MOU)

The Privacy Office
U.S. Department of Homeland Security
Washington, DC 20528
703-235-0780, pia@dhs.gov
www.dhs.gov/privacy

Privacy Threshold Analysis
Version date: June 10th, 2009
Page 7 of 7
PRIVACY THRESHOLD REVIEW
(To be Completed by the DHS Privacy Office)

DATE reviewed by the DHS Privacy Office: February 25, 2010
NAME of the DHS Privacy Office Reviewer: Rebecca J. Richards
DESIGNATION
This is NOT a Privacy Sensitive System – the system contains no Personally Identifiable
Information.
This IS a Privacy Sensitive System
Category of System
IT System
National Security System
Legacy System
HR System
Rule
Other:
Determination
PTA sufficient at this time
Privacy compliance documentation determination in progress
PIA is not required at this time
A PIA is required
System covered by existing PIA: USCIS IDDMP PIA
A new PIA is required.
A PIA Update is required.
A SORN is required
System covered by existing SORN: DHS/USCIS-001
A new SORN is required.
DHS PRIVACY OFFICE COMMENTS