1625-0008 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.
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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)

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:

CG-4423

Form Title:

Application for Marine Event

Component:

U.S. Coast Guard (USCG) Office:

CG-WWM-1

IF COVERED BY THE PAPERWORK REDUCTION ACT:
Regattas and Marine Parades
Collection Title:
OMB Control
Number:
Collection status:

Name:
Office:
Phone:

Name:
Office:
Phone:

1625-0008
Extension

OMB Expiration
Date:
Date of last PTA (if
applicable):

September 30, 2017
October 1, 2014

PROJECT OR PROGRAM MANAGER
CDR Justin W. Jacobs
CG-WWM-1
Staff Officer
Title:
202-372-1530
Justin.w.jacobs@uscg.mil
Email:

COMPONENT INFORMATION COLLECTION/FORMS CONTACT
Anthony Smith
CG-612
PRA Manager
Title:
202-475-3532
Anthony.D.Smith@uscg.mil
Email:

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Privacy Office
U.S. Department of Homeland Security
Washington, DC 20528
202-343-1717, pia@hq.dhs.gov
www.dhs.gov/privacy

SPECIFIC IC/Forms PTA QUESTIONS
1. Purpose of the Information Collection or Form
The permit application provides the Coast Guard with the minimum information needed to
identify the marine event and the event contact to consider whether or not an event is likely to
result in the loss of human life unless special precautions are taken.
Marine events may actually block navigation channels or cause interference with adjacent
vessel traffic or with the ability of larger commercial vessels to safely navigate designated
shipping lanes. Also, adjacent vessel traffic may interfere with the safety or conduct of the
marine event.
CG Form 4423 contains basic business contact information which may include the name,
address, and phone number of any event sponsor wishing to conduct activity that may block,
or impede safe navigation on the navigable waters of the United States.
Information is collected in accordance with 33 CFR 100.

2. Describe the IC/Form
a. Does this form collect any
Personally Identifiable
Information” (PII 1)?

b. From which type(s) of
individuals does this form
collect information? (Check
all that apply.)

x Yes
☐ No

x Members of the public
x U.S. citizens or lawful permanent
residents
☐ Non-U.S. Persons.

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.

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Privacy Office
U.S. Department of Homeland Security
Washington, DC 20528
202-343-1717, pia@hq.dhs.gov
www.dhs.gov/privacy

☐ DHS Employees
☐ DHS Contractors
☐ Other federal employees or contractors.

c. Who will complete and
submit this form? (Check all
that apply.)

x 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.
Click here to enter text.

d. How do individuals complete
the form? Check all that
apply.

x Paper.
x Electronic. (ex: fillable PDF)
x Online web form. (available and submitted via
the internet)
Provide link:
https://homeport.uscg.mil/mycg/portal/ep/mari
ne_event/marine_event_form.jsp

e. What information will DHS collect on the form?
Name, address, and phone number.
f. Does this form collect Social Security number (SSN) or other element that is standalone Sensitive Personally Identifiable Information (SPII)? No.
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Privacy Office
U.S. Department of Homeland Security
Washington, DC 20528
202-343-1717, pia@hq.dhs.gov
www.dhs.gov/privacy

☐ Social Security
number
☐ Alien Number (ANumber)
☐ 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

g. List the specific authority to collect SSN or these other SPII elements.
N/A.
h. 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.
N/A.
i. 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)?

x☐ Yes. Please describe how notice is provided.
The Privacy Act Statement is placed on the bottom
of Form CG-4423.
☐ No.

3. How will DHS store the IC/form responses?

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Privacy Office
U.S. Department of Homeland Security
Washington, DC 20528
202-343-1717, pia@hq.dhs.gov
www.dhs.gov/privacy

a. How will DHS store
the original,
completed IC/forms?

☐ Paper. Please describe.
Click here to enter text.
☐ Electronic. Please describe the IT system that will
store the data from the form.
Click here to enter text.
x☐ Scanned forms (completed forms are scanned
into an electronic repository). Please describe the
electronic repository.
Scanned forms are entered into the Marine
Information for Safety and Law Enforcement (MISLE)
database which is the CG's resource for information for
marine safety, law enforcement, search and rescue,
geographical information systems, commercial fishing
vessel safety and many other aspects of CG operations.
It is an administrative record.

b. If electronic, how
does DHS input the
responses into the IT
system?

x Manually (data elements manually entered). Please
describe.
Authorized USCG personnel manually enter scanned
documents into the MISLE database for
administrative record purposes.
☐ Automatically. Please describe.
Click here to enter text.

c. How would a user
search the
information
submitted on the
forms, i.e., how is the
information
retrieved?
d. What is the records
retention

☐ By a unique identifier. 2 Please describe. If
information is retrieved by personal identifier, please
submit a Privacy Act Statement with this PTA.
Click here to enter text.
x By a non-personal identifier. Please describe.
Each MISLE activity is assigned a non-personal
identifier (Activity Number) and does not include any
PII.
Records are Permanent: Cut off all associated case and
activity data with their attachment pertaining to a case at

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.

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Privacy Office
U.S. Department of Homeland Security
Washington, DC 20528
202-343-1717, pia@hq.dhs.gov
www.dhs.gov/privacy

schedule(s)? Include
the records schedule
number.

end of calendar year in which the case is closed.
Transfer to the National Archives 5 years blocks
immediately after the latest cutoff. NARA retention
schedule number N1-026-05-015.
As records are maintained in the MISLE database,
disposal/deletion is in accordance with the business rules for
the database.

e. How do you ensure
that records are
disposed of or deleted
in accordance with
the retention
schedule?
f. 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?

x Yes, information is shared with other DHS components or offices. Please describe.
The information is not explicitly shared, but is accessible to MISLE users if they
choose to search for specific information regarding Marine Event Permits. The form is
typically scanned and uploaded to the corresponding MISLE activity report.
☐ Yes, information is shared external to DHS with other federal agencies, state/local
partners, international partners, or non-governmental entities. Please describe.
Click here to enter text.

☐ 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.

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Privacy Office
U.S. Department of Homeland Security
Washington, DC 20528
202-343-1717, pia@hq.dhs.gov
www.dhs.gov/privacy

PRIVACY THRESHOLD REVIEW
(TO BE COMPLETED BY COMPONENT PRIVACY OFFICE)
Component Privacy Office
Reviewer:

Kenlinishia Tyler

Date submitted to component
Privacy Office:
Date submitted to DHS Privacy
Office:
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.)

September 9, 2016
Nov. 3, 2016
☐ Yes. Please include it with this PTA
submission.
x No. Please describe why not.
The Privacy Act Statement has been in
existence and is on the bottom of the form.

Component Privacy Office Recommendation:
Please include recommendation below, including what existing privacy compliance
documentation is available or new privacy compliance documentation is needed.
CG Form 4423 is utilized to provide the Coast Guard with the minimum information needed to
identify the marine event and the event contact to consider whether or not an event is likely to
result in the loss of human life unless special precautions are taken.
The Coast Guard will use this information to determine whether an event poses an extra or
unusual hazard to the safety of life and whether or not, and under which conditions, to permit the
event on the navigable waters of the United States.
A member completes/submits the CG-4423. CG-4423 is scanned and uploaded/retained in the
Marine Information for Safety and Law Enforcement (MISLE) database.
DHS/USCG/PIA-008 and DHS/USCG-013 provides coverage for this collection.

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Privacy Office
U.S. Department of Homeland Security
Washington, DC 20528
202-343-1717, pia@hq.dhs.gov
www.dhs.gov/privacy

PRIVACY THRESHOLD ADJUDICATION
(TO BE COMPLETED BY THE DHS PRIVACY OFFICE)
DHS Privacy Office Reviewer:

Michael Capparra

PCTS Workflow Number:
Date approved by DHS Privacy Office:
PTA Expiration Date

1134517
November 4, 2016
November 4, 2019

DESIGNATION

Privacy Sensitive IC or
Form:

Yes If “no” PTA adjudication is complete.

DHS IC/Forms Review:

DHS PRIV has approved this ICR/Form.

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.

Date IC/Form Approved November 4, 2016
by PRIV:
IC/Form PCTS Number: 1134517
Privacy Act
Choose an item.
Statement:
Click here to enter text.
PTA:
Choose an item.
Click here to enter text.
PIA:
System covered by existing PIA
Privacy Threshold Analysis – IC/Form

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Privacy Office
U.S. Department of Homeland Security
Washington, DC 20528
202-343-1717, pia@hq.dhs.gov
www.dhs.gov/privacy

If covered by existing PIA, please list: DHS/USCG/PIA-008 Marine
Information for Safety and Law Enforcement (MISLE) 2009
If a PIA update is required, please list: Click here to enter text.
SORN:
System covered by existing SORN
If covered by existing SORN, please list: DHS/USCG-013 - Marine
Information for Safety and Law Enforcement (MISLE), June 25, 2009 74
FR 30305
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.

The DHS Privacy Office finds that the Application for Marine Event Form CG-4423
represents a privacy sensitive collection, requiring a Privacy Act Statement, as well as PIA
and SORN coverage. The form, which collects information regarding marine events
(blockage or interference with navigational channels or vessel traffic) in order to allow the
Coast Guard to determine whether or not an event is likely to result the loss of human life if
special precautions are not taken. CG Form 4423 collets the basic business contact
information which may include the name, address, and phone number of any sponsor for
an event or activity that may impede safe navigation on the navigable waters of the United
States. PIA coverage is provided by DHS/USCG/PIA-008 Marine Information for Safety and
Law Enforcement (MISLE) 2009, which assess the collection of information, including PII,
associated with vessels as well as investigatory information. SORN coverage is provided by
DHS/USCG-013, which outlines the Coast Guard’s collection and maintenance of records
related to safety, security and law enforcement performance history of vessels, facilities,
people and organizations engaged in marine transportation, including enforcement action,
that can be used to identify and address safety, security and environmental risks and to
establish vessel eligibility for documentation as a U.S. flag vessel. A Privacy Act statement is
included within the form.

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