Forms PTA

Privacy Office

U.S. Department of Homeland Security

Washington, DC 20528

202-343-1717, pia@hq.dhs.gov

www.dhs.gov/privacy

PRIVACY THRESHOLD ANALYSIS (PTA)

This form serves as the official determination by the DHS Privacy Office to identify the privacy compliance requirements for all Departmental uses of personally identifiable information (PII).

A Privacy Threshold Analysis (PTA) serves as the document used to identify information technology (IT) systems, information collections/forms, technologies, rulemakings, programs, information sharing arrangements, or pilot projects that involve PII and other activities that otherwise impact the privacy of individuals as determined by the Chief Privacy Officer, pursuant to Section 222 of the Homeland Security Act, and to assess whether there is a need for additional Privacy Compliance Documentation. A PTA includes a general description of the IT system, information collection, form, technology, rulemaking, program, pilot project, information sharing arrangement, or other Department activity and describes what PII is collected (and from whom) and how that information is used and managed.

Please complete the attached Privacy Threshold Analysis and submit it to your component Privacy Office. After review by your component Privacy Officer the PTA is sent to the Department’s Senior Director for Privacy Compliance for action. If you do not have a component Privacy Office, please send the PTA to the DHS Privacy Office:

Senior Director, Privacy Compliance

The Privacy Office

U.S. Department of Homeland Security

Washington, DC 20528

Tel: 202-343-1717

PIA@hq.dhs.gov

Upon receipt from your component Privacy Office, the DHS Privacy Office will review this form and assess whether any privacy compliance documentation is required. If compliance documentation is required – such as Privacy Impact Assessment (PIA), System of Records Notice (SORN), Privacy Act Statement, or Computer Matching Agreement (CMA) – the DHS Privacy Office or component Privacy Office will send you a copy of the relevant compliance template to complete and return.

Privacy Threshold Analysis (PTA)

Specialized Template for

Information Collections (IC) and Forms

The Forms-PTA is a specialized template for Information Collections and Forms. This specialized PTA must accompany all Information Collections submitted as part of the Paperwork Reduction Act process (any instrument for collection (form, survey, questionnaire, etc.) from ten or more members of the public). Components may use this PTA to assess internal, component-specific forms as well.

Form Number:	ICE Form G-146
Form Title:	Non-Immigrant Checkout Letter
Component:			Office:	Enforcement and Removal Operations

If covered by the paperwork reduction act:

Collection Title:	Non-Immigrant Checkout Letter
OMB Control Number:		1653-0020		OMB Expiration Date:	March 31, 2017
Collection status:				Date of last PTA (if applicable):		Not applicable

PROJECT OR PROGRAM MANAGER

Name:	Daniel D’Arrigo
Office:	Enforcement and Removal Operations	Title:	Detention and Deportation Officer
Phone:	202-732-3465	Email:	Daniel.d’arrigo@ice.dhs.gov

COMPONENT Information Collection/FORMS contact

Name:	Scott A. Elmore
Office:	Office of the Chief Information Officer	Title:	ICE Forms Manager/PRA Clearance Officer
Phone:	202-732-2601	Email:	scott.a.elmore@ice.dhs.gov

SPECIFIC IC/Forms PTA QUESTIONS

1. Purpose of the Information Collection or Form

1. Describe the purpose of the information collection or form. Please provide a general description of the project and its purpose, including how it supports the DHS mission, in a way a non-technical person could understand (you may use information from the Supporting Statement).

If this is an updated PTA, please specifically describe what changes or upgrades are triggering the update to this PTA.

The primary purpose of ICE Form G-146, Non-Immigrant Checkout Letter, is to document that an alien voluntarily departed the United States pursuant to an order from an Immigration Judge granting the alien the right to depart voluntarily. An ICE officer completes the top portion of the form, filling in the alien’s name and Alien Number (A-number). The officer then gives the form to the alien. The alien presents the form to any “Authorized U.S. Official” (e.g., U.S. embassy or consulate personnel) who certifies that the alien departed the United States. Alternatively, the U.S. official may indicate that the alien did not depart the United States for a valid reason. As indicated on the form, such reasons include the alien applying for or being granted an extension of temporary stay, or applying for adjustment of status. Finally, the form may be used to document that an alien did not depart the United States for an unknown reason. In this scenario, a U.S. official may use the form to provide contact information for the alien or others who may have knowledge of the alien’s whereabouts.

2. List the DHS (or component) authorities to collect, store, and use this information. If this information will be stored and used by a specific DHS component, list the component-specific authorities.

ICE is authorized to collect, store, and use this information under the following authorities: sections 101, 222(g), 212(a)(9)B(i)(I) and (II), 214(a)(1), and 217(a)(7)of the Immigration and Nationality Act; and 8 C.F.R. § 215.8(a)(1) and 235.1(f)(1)(ii).

Describe the IC/Form
Does this form collect any Personally Identifiable Information” (PII1)?		☒ Yes ☐ No
From which type(s) of individuals does this form collect information? (Check all that apply.)		☒ Members of the public ☒ U.S. citizens or lawful permanent residents ☒ Non-U.S. Persons. ☒ DHS Employees ☐ DHS Contractors ☒ Other federal employees or contractors.
Who will complete and submit this form? (Check all that apply.)		☐ The record subject of the form (e.g., the individual applicant). ☐ Legal Representative (preparer, attorney, etc.). ☐ Business entity. If a business entity, is the only information collected business contact information? ☐ Yes ☐ No ☒ Law enforcement. ☒ DHS employee or contractor. ☒ Other individual/entity/organization that is NOT the record subject. Please describe. Embassy or consulate personnel may complete the second section of the form.
How do individuals complete the form? Check all that apply.		☒ Paper. ☒ Electronic. (ex: fillable PDF) ☐ Online web form. (available and submitted via the internet) Provide link:
What information will DHS collect on the form? List all PII data elements on the form. If the form will collect information from more than one type of individual, please break down list of data elements collected by type of individual.
The alien’s name and A-number, provided by an ICE officer, appear in the top half of the form. The form may also collect contact information (name and address) for the alien and/or individuals who may have knowledge of the alien’s whereabouts. Finally, the form collects contact information (name and address) for the U.S. official completing the form.
Does this form collect Social Security number (SSN) or other element that is stand-alone Sensitive Personally Identifiable Information (SPII)? Check all that apply.
☐ Social Security number ☒ Alien Number (A-Number) ☐ Tax Identification Number ☐ Visa Number ☐ Passport Number ☐ Bank Account, Credit Card, or other financial account number ☐ Other. Please list:			☐ DHS Electronic Data Interchange Personal Identifier (EDIPI) ☐ Social Media Handle/ID ☐ Known Traveler Number ☐ Trusted Traveler Number (Global Entry, Pre-Check, etc.) ☐ Driver’s License Number ☐ Biometrics
List the specific authority to collect SSN or these other SPII elements.
ICE is authorized to collect, store, and use this information under the following authorities: sections 101, 222(g), 212(a)(9)B(i)(I) and (II), 214(a)(1), and 217(a)(7)of the Immigration and Nationality Act; and 8 C.F.R. § 215.8(a)(1) and 235.1(f)(1)(ii).
How will this information be used? What is the purpose of the collection? Describe why this collection of SPII is the minimum amount of information necessary to accomplish the purpose of the program.
The ICE officer completing the top portion of the form places the A-number on the form as a definitive means of identifying the alien. In addition, after the form is completed, the A-number is used to file the form in the correct Alien File (A-file).
Are individuals provided notice at the time of collection by DHS (Does the records subject have notice of the collection or is form filled out by third party)?	☒ Yes. After the ICE officer completes the top portion of the form, the officer gives it to the alien for delivery to a U.S. official, who completes the remainder of the form. Thus, although the form is filled out by third parties (the ICE officer and a U.S. official), the alien has notice of the information being collected. ☐ No.

How will DHS store the IC/form responses?
How will DHS store the original, completed IC/forms?	☒ Paper. Please describe. The form will be stored in the A-file, which is a paper file. ☐ Electronic. Please describe the IT system that will store the data from the form. ☒ Scanned forms (completed forms are scanned into an electronic repository). Please describe the electronic repository. If the A-file has been digitized, the form will be scanned and stored in the Enterprise Document Management System (EDMS). EDMS is a web-based portal that allows authorized users to access A-files that have been digitized.
If electronic, how does DHS input the responses into the IT system?	☐ Manually (data elements manually entered). Please describe. N/A. ☐ Automatically. Please describe. N/A.
How would a user search the information submitted on the forms, i.e., how is the information retrieved?	☒ By a unique identifier.2 Please describe. If information is retrieved by personal identifier, please submit a Privacy Act Statement with this PTA. If the A-file has not been digitized, a user would first obtain the paper A-file using the A-number, and then page through the file to locate the form. If the A-file has been digitized, a user would locate the A-file in EDMS using the A-number. The user would then see a list of the form names and form numbers contained in the A-file (e.g., “G-146 – Non-Immigrant Checkout Letter”). The user would click on the form of interest to view it. ☐ By a non-personal identifier. Please describe.
What is the records retention schedule(s)? Include the records schedule number.	The form is maintained as part of an individual’s A-file, which is covered by USCIS Schedule N1-566-08-011. Based on this schedule, the form is maintained permanently.
How do you ensure that records are disposed of or deleted in accordance with the retention schedule?	Not applicable. Because the A-file is permanent, its contents will not be disposed of or deleted.
Is any of this information shared outside of the original program/office? If yes, describe where (other offices or DHS components or external entities) and why. What are the authorities of the receiving party?
☐ Yes, information is shared with other DHS components or offices. Please describe. Click here to enter text. ☒ Yes, information is shared external to DHS with other federal agencies, state/local partners, international partners, or non-governmental entities. Please describe. Individuals who have access to A-files or EDMS would be able to view the form. ☐ No. Information on this form is not shared outside of the collecting office.

Please include a copy of the referenced form and Privacy Act Statement (if applicable) with this PTA upon submission.

PRIVACY THRESHOLD REVIEW

(To be Completed by COMPONENT PRIVACY OFFICE)

Component Privacy Office Reviewer:	Jeffery R. Knight
Date submitted to component Privacy Office:	March 31, 2017
Date submitted to DHS Privacy Office:	March 31, 2017
Have you approved a Privacy Act Statement for this form? (Only applicable if you have received a waiver from the DHS Chief Privacy Officer to approve component Privacy Act Statements.)	☒ Yes. Please include it with this PTA submission. ☐ No. Please describe why not.
Component Privacy Office Recommendation: Please include recommendation below, including what existing privacy compliance documentation is available or new privacy compliance documentation is needed.
The ICE Office of Information Governance and Privacy recommends approval of the three-year renewal of ICE Form G-146, Non-Immigrant Checkout Letter. The information on this form may be used as necessary and is authorized by the routine uses published in the Alien File (A-File), Index, and National File Tracking System of Records Notice (SORN) (78 FR 69864, November 21, 2013).

PRIVACY THRESHOLD ADJUDICATION

(To be Completed by the DHS Privacy Office)

DHS Privacy Office Reviewer:	Click here to enter text.
PCTS Workflow Number:	Click here to enter text.
Date approved by DHS Privacy Office:	Click here to enter a date.
PTA Expiration Date	Click here to enter a date.

DESIGNATION

Privacy Sensitive IC or Form:		If “no” PTA adjudication is complete.
Determination:		☐ PTA sufficient at this time. ☐ Privacy compliance documentation determination in progress. ☐ New information sharing arrangement is required. ☐ DHS Policy for Computer-Readable Extracts Containing SPII applies. ☐ Privacy Act Statement required. ☐ Privacy Impact Assessment (PIA) required. ☐ System of Records Notice (SORN) required. ☐ Specialized training required. ☐ Other. Click here to enter text.
DHS IC/Forms Review:
Date IC/Form Approved by PRIV:		Click here to enter a date.
IC/Form PCTS Number:		Click here to enter text.
Privacy Act Statement:	Click here to enter text.
PTA:	Click here to enter text.
PIA:	If covered by existing PIA, please list: Click here to enter text. If a PIA update is required, please list: Click here to enter text.
SORN:	If covered by existing SORN, please list: Click here to enter text. If a SORN update is required, please list: Click here to enter text.
DHS Privacy Office Comments: Please describe rationale for privacy compliance determination above.
Click here to enter text.

1 Personally identifiable information means any information that permits the identity of an individual to be directly or indirectly inferred, including any other information which is linked or linkable to that individual regardless of whether the individual is a U.S. citizen, lawful permanent resident, visitor to the U.S., or employee or contractor to the Department.

2 Generally, a unique identifier is considered any type of “personally identifiable information,” meaning any information that permits the identity of an individual to be directly or indirectly inferred, including any other information which is linked or linkable to that individual regardless of whether the individual is a U.S. citizen, lawful permanent resident, visitor to the U.S., or employee or contractor to the Department.

Privacy Threshold Analysis – IC/Form Version number: 04-2016

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