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: April 27, 2010
Page 1 of 6

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 from the component Privacy Office, 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 DHSConnect 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: April 27, 2010
Page 2 of 6

PRIVACY THRESHOLD ANALYSIS (PTA)
SUMMARY INFORMATION
DATE submitted for review: 4-5-11
NAME of Project: Form I-905, Application for Authorization to Issue Certification of Health
Care Workers
Name of Component: U.S. Citizenship and Immigration Services
Name of Project Manager: Essie 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 Rule.
Form or other Information Collection.
Other:



The E-Government Act of 2002 defines these terms by reference to the definition sections of Titles 40 and
44 of the United States Code. The following is a summary of those definitions:
•“Information Technology” means any equipment or interconnected system or subsystem of
equipment, used in the automatic acquisition, storage, manipulation, management, movement,
control, display, switching, interchange, transmission, or reception of data or information. See 40
U.S.C. § 11101(6).
•“Information System” means a discrete set of information resources organized for the collection,
processing, maintenance, use, sharing, dissemination, or disposition of information. See: 44. U.S.C. §
3502(8).
Note: for purposes of this form, there is no distinction made between national security systems or
technologies/systems managed by contractors. All technologies/systems should be initially reviewed for
potential privacy impact.

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: April 27, 2010
Page 3 of 6
SPECIFIC QUESTIONS
1.

Describe the project and its purpose:
The purpose of this application is for an organization to apply for authorization to issue
certificates to health care workers.

2.

Status of Project:
This is a new development effort.
This is an existing project.
Date first developed:
Date last updated:
This is a request to extend the use of Form I-905 under the Paperwork Reduction Act.
The form is set to expire on August 31, 2011.

3.

Could the project relate in any way to an individual?1
No. Please skip ahead to the next question.
Yes. Please provide a general description, below.

4.

Do you collect, process, or retain information on: (Please check all that apply)
DHS Employees.
Contractors working on behalf of DHS.
The Public.
The System does not contain any such information.

1

Projects can relate to individuals in a number of ways. For example, a project may include a camera for
the purpose of watching a physical location. Individuals may walk past the camera and images of those
individuals may be recorded. Projects could also relate to individuals in more subtle ways. For example,
a project that is focused on detecting radioactivity levels may be sensitive enough to detect whether an
individual received chemotherapy.

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: April 27, 2010
Page 4 of 6
5.

Do you use or collect Social Security Numbers (SSNs)? (This includes truncated SSNs)
No.
Yes. Why does the program collect SSNs? Provide the function of the SSN and the
legal authority to do so:

6.

What information about individuals could be collected, generated or retained?
The form collects information about an organization in addition to the person’s name,
address to include email, and phone number to include fax of the person preparing the form.

7.

If this project is a technology/system, does it relate solely to infrastructure? [For example, is
the system a Local Area Network (LAN) or Wide Area Network (WAN)]?
No. Please continue to the next question.
Yes. Is there a log kept of communication traffic?
No. Please continue to the next question.
Yes. What type of data is recorded in the log? (Please choose all that apply.)
Header.
Payload Please describe the data that is logged.

8.

Does the system connect, receive, or share Personally Identifiable Information with any other
DHS systems2?
No.
Yes.
Please list:

2

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.

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: April 27, 2010
Page 5 of 6
9.

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

Low

Moderate

High

Undefined

Integrity:

Low

Moderate

High

Undefined

Availability:

Low

Moderate

High

Undefined

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: April 27, 2010
Page 6 of 6
PRIVACY THRESHOLD REVIEW
(TO BE COMPLETED BY THE DHS PRIVACY OFFICE)
DATE reviewed by the DHS Privacy Office: April 15, 2011
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: Form
Determination
PTA sufficient at this time.
Privacy compliance documentation determination in progress.
PIA is not required at this time.
PIA is required.
System covered by existing PIA: CLAIMS 3
New PIA is required.
PIA update is required.
SORN not required at this time.
SORN is required.
System covered by existing SORN: DHS/USCIS-007
New SORN is required.
DHS PRIVACY OFFICE COMMENTS