Privacy Threshold Analysis (PTA), FEMA Form 080-0-4

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 – IC/Form

Page 1 of 11

Version number: 04-2016

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:

FEMA Form 080-0-0-4

Form Title:

Staffing for Adequate Fire and Emergency Response (General
Questions All Applicants)

Component:

Federal Emergency
Management Agency
(FEMA)

Office:

Assistance to
Firefighters Grant
Programs (AFGP)

IF COVERED BY THE PAPERWORK REDUCTION ACT:
Collection Title:
Staffing for Adequate Fire and Emergency Response
OMB Control
Number:
Collection status:

Name:
Office:
Phone:

1660-0135
Choose an item.

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

August 31, 2017
January 1, 2014

PROJECT OR PROGRAM MANAGER
Catherine Patterson
Assistance to Firefighters
Title:
Branch Chief
Grant Programs
202-786-9796
Email:
Catherine.Patterson@fema.d
hs.gov

Privacy Threshold Analysis – IC/Form

Page 2 of 11

Version number: 04-2016

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

Name:
Office:
Phone:

COMPONENT INFORMATION COLLECTION/FORMS CONTACT
William Dunham
Assistance to Firefighters
Title:
Fire Program Specialist
Grant Programs
202-786-9813
Email:
William.Dunham@fema.dhs.
gov
SPECIFIC IC/Forms PTA QUESTIONS

1. Purpose of the Information Collection or Form
a. 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.
This PTA is being submitted to document the general application information collected
from applicants to the Staffing for Adequate Fire and Emergency Response (SAFER) Grant
Program.
The SAFER Grant Program is a competitive grant opportunity that is administered by the
Assistance to Firefighters Program Office. The goal of the SAFER grant program is to assist
local fire departments with staffing and deployment capabilities in order to respond to
emergencies, and assure that communities have adequate protection from fire and firerelated hazards. The SAFER grant application package is included in the Office of
Management and Budget (OMB) Information Collection Request (ICR) 1660-0135.
The purpose of the collection is to assess the needs of each individual applicant compared
to the other applicants interested in the SAFER funding opportunity. Applicants to the
SAFER grant program are state, county, and municipal organizations/entities in charge of
administering firefighting duties.
The SAFER application package has three components. There is the SAFER general
questionnaire (FEMA Form 080-0-0-4), the Hiring of Firefighters questionnaire (FEMA
Form 080-0-0-4a), and the Recruitment and Retention of Volunteer Firefighters
questionnaire (FEMA Form 080-0-0-4b). For a complete application submission either
the Hiring of Firefighters questionnaire or the Recruitment and Retention of Volunteer
Firefighters questionnaire are required with the SAFER general questionnaire.
Privacy Threshold Analysis – IC/Form

Page 3 of 11

Version number: 04-2016

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

SAFER General Questions for All Applicants form, FEMA Form 080-0-0-4, is used to obtain
general information regarding the applicant such as name, address, organization banking
information, contact information, and type of organization. It also includes questions
regarding the general characteristics of the applicant’s community such as zoning and
population protected. Finally, it obtains information regarding the staffing levels and
needs of the applicant, the number of firefighters, both full and part-time, and the number
and types of incidents the department responds to.
This submission is necessary in order for DHS to effectively implement a competitive grant
program and meet the fiscal deadlines. The data generated through the grant application
process is stored and maintained in the E-grants system. This system does not relate to
any other grant application system such as Non‐Disaster (ND) Grants.
b. 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.
The authority for Staffing for Adequate Fire and Emergency Response (SAFER) is derived
from the Federal Fire Protection and Control Act of 1974 (15 U.S.C. §§ 2229 et seq.), as
amended.

2. Describe the IC/Form
a. Does this form collect any
Personally Identifiable
Information” (PII1)?
b. From which type(s) of
individuals does this form
collect information?
(Check all that apply.)

☒ Yes
☐ No
☒ Members of the public
☒ U.S. citizens or lawful permanent
residents
☐ Non-U.S. Persons.
☐ DHS Employees
☐ DHS Contractors
☐ Other federal employees or contractors.

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.
Privacy Threshold Analysis – IC/Form

Page 4 of 11

Version number: 04-2016

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

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

d. How do individuals
complete the 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.
This form will be completed by a firefighter
organization’s point of contact.
☐ Paper.

☐ Electronic. (ex: fillable PDF)
☒ Online web form. (available and submitted via
the internet)
Provide link: https://portal.fema.gov/
e. 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.
FEMA collects the following information from preparers, points of contact, and alternate
points of contacts:
Name;
Address;
Title;
Telephone Number;
Fax Number; and
Email.
f. Does this form collect Social Security number (SSN) or other element that is
stand-alone Sensitive Personally Identifiable Information (SPII)? Check all that
apply. N/A
Privacy Threshold Analysis – IC/Form

Page 5 of 11

Version number: 04-2016

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 (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

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)?

☒ Yes. Please describe how notice is provided.
A privacy notice will be provided.
☐ No.

3. How will DHS store the IC/form responses?
a. How will DHS store
☐ Paper. Please describe.
the original,
Click here to enter text.
completed IC/forms?
☒ Electronic. Please describe the IT system that will
store the data from the form.
Information will be stored in E-grants system.

Privacy Threshold Analysis – IC/Form

Page 6 of 11

Version number: 04-2016

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

☐ Scanned forms (completed forms are scanned into
an electronic repository). Please describe the
electronic repository.
Click here to enter text.
b. If electronic, how
does DHS input the
responses into the IT
system?

☐ Manually (data elements manually entered). Please
describe.
Click here to enter text.
☒ Automatically. Please describe.
Respondents enter the information directly into
the E-grants system. DHS does not input
responses.

c. 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.
Click here to enter text.
☒ By a non-personal identifier. Please describe.
The AFG Office retrieves information by an autogenerated application number. The application
number is linked to the firefighter organization’s
application, rather than an individual.
Records are destroyed 10 years after final action is
taken on file, but longer retention is authorized if
required for business use, per PRC-12-1 (207-080-121).

d. What is the records
retention
schedule(s)? Include
the records schedule
number.
e. How do you ensure
that records are
disposed of or deleted
in accordance with
the retention
schedule?

The AFG staff adheres to the FEMA Disposition
schedule, to ensure compliance with the records
retention schedule, which outlines timelines,
description of files for records destruction, and or
disposal of relevant documents associated with each
grant program.

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

Page 7 of 11

Version number: 04-2016

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

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?
☐ 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.
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.

Privacy Threshold Analysis – IC/Form

Page 8 of 11

Version number: 04-2016

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:

Christopher Rogers

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

June 16, 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.)

Click here to enter a date.
☐ Yes. Please include it with this PTA
submission.
☒ No. Please describe why not.
The form is not retrieved by personal
identifier. Therefore, no System of Record
exists.

Component Privacy Office Recommendation:
Please include recommendation below, including what existing privacy compliance
documentation is available or new privacy compliance documentation is needed.
FEMA Privacy recommends the following coverage:
PIA: DHS/FEMA/PIA-013;
SORN: Not applicable as the program is not retrieving the form by personal identifier.
Therefore, no System of Record exists.

Privacy Threshold Analysis – IC/Form

Page 9 of 11

Version number: 04-2016

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:

Hannah Burgess

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

1146133
July 31, 2017
July 31, 2020

DESIGNATION
Privacy Sensitive IC or
Form:

Yes 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:

DHS PRIV has approved this ICR/Form.

Date IC/Form Approved Click here to enter a date.
by PRIV:
IC/Form PCTS Number: Click here to enter text.
Privacy Act
New e(3) statement is required.
Statement:
SAFER Privacy Notice OMB 1660-0135
PTA:
Updated system PTA required.
Click here to enter text.
PIA:
System covered by existing PIA
Privacy Threshold Analysis – IC/Form

Page 10 of 11

Version number: 04-2016

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: FEMA/PIA-013 Grant
Management Programs
If a PIA update is required, please list: Click here to enter text.
SORN:
If covered by existing SORN, please list:
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.
FEMA is submitting this PTA for the Staffing for Adequate Fire and Emergency Response
(SAFER) form (080-0-0-4), which is part of OMB ICR (1660-0135). The SAFER Grant
Program is a competitive grant opportunity that is administered by the Assistance to
Firefighters Program Office. The goal of the SAFER grant program is to assist local fire
departments with staffing and deployment capabilities in order to respond to emergencies,
and assure that communities have adequate protection from fire and fire-related hazards.
Form 080-0-0-4 is used to obtain general information regarding the applicant such as point
of contact name, address, organization banking information, contact information, and type
of organization. This submission is necessary in order for DHS to effectively implement a
competitive grant program and meet the fiscal deadlines.
The DHS Privacy Office agrees with FEMA that this form is a privacy-sensitive collection
that requires PIA coverage. Coverage is provided by FEMA/PIA-013 Grant Management
Programs as part of the Non-Disaster Grant application process. The Privacy Office also
agrees that no SORN coverage is required, because information is retrieved by an autogenerated application number linked to a firefighter organization, not an individual. Form
080-0-0-4 requires a Privacy Notice, which was submitted and approved along with this
PTA.

Privacy Threshold Analysis – IC/Form

Page 11 of 11

Version number: 04-2016