1625-0121 Pta

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

ILEPRIVACY 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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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:

USCGA-AIM3

Form Title:

Academy Introduction Mission (AIM) Medical Release Form

Component:

U.S. Coast Guard (USCG)

Office:

USCGA Admissions

IF COVERED BY THE PAPERWORK REDUCTION ACT:
Collection Title:
OMB Control
Number:
Collection status:

United States Coast Guard Academy Introduction Mission Program Application
and Supplemental Forms
1625-0121
February 28, 2018
OMB Expiration
New Collection

Date:
Date of last PTA (if
applicable):

N/A

PROJECT OR PROGRAM MANAGER
Name:
Office:
Phone:

LT Alexander Eames

Title:
Email:

USCGA Admissions
860-701-6395

Campus Programs Manager
Alexander.g.eames@uscga.edu

COMPONENT INFORMATION COLLECTION/FORMS CONTACT
Name:
Office:
Phone:

Anthony Smith

Title:
Email:

CG-612
202-475-3532

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PRA Coordinator
Anthony.D.Smith@uscg.mil

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

SPECIFIC IC/Forms PTA QUESTIONS
1. Purpose of the Information Collection or Form
The purpose of this form is for students accepted to and attending the summer AIM program the ability
to receive medical clearance from their primary care physician and for parents to release liability for
personal injury while their son or daughter attends the AIM program.
This information is used to obtain medical clearance from their primary care physician and for parents
to release liability for personal injury while their son or daughter attends the US Coast Guard Academy
for the week long AIM program, a one-week summer orientation which allows select rising high
school seniors to experience cadet life at the USCGA and is designed to recruit the future Officers of
the US Coast Guard.
The authority to operate the United States Coast Guard Academy (USCGA) is contained in 14 USC
181. The regulation and administration of the USCGA is the responsibility of the Superintendent,
subject to the direction of the Commandant of the Coast Guard under the general supervision of the
Secretary of Homeland Security. One of the Superintendent’s responsibilities is to ensure that eligible
individuals from the public at large have every opportunity to visit and learn about the USCGA.

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.)

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

X Yes
☐ No
X Members of the public
X U.S. citizens or lawful permanent
residents
X Non-U.S. Persons.
☐ DHS Employees
☐ DHS Contractors
☐ Other federal employees or contractors.
X The record subject of the form (e.g., the
individual applicant).

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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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

☐ 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.
X Other individual/entity/organization that is
NOT the record subject. Please describe.
Parent and examiner.

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

X Paper.
X Electronic. (ex: fillable PDF)
☐ Online web form. (available and submitted via
the internet)
Provide link:

e. What information will DHS collect on the form?
Student: Name, date of birth, and medical history.
Parent/Legal Guardian: Name, address, telephone number and email address.
Examiner: Name, title, address, telephone number, and fax number.

f. Does this form collect Social Security number (SSN) or other element that is
stand-alone Sensitive Personally Identifiable Information (SPII)? No.
☐ Social Security number
☐ DHS Electronic Data Interchange
Personal Identifier (EDIPI)
☐ Alien Number (A-Number)
☐ Social Media Handle/ID
☐ Tax Identification Number
☐ Known Traveler Number
☐ Visa Number
☐ Trusted Traveler Number (Global
☐ Passport Number
Entry, Pre-Check, etc.)
☐ Bank Account, Credit Card, or other
☐ Driver’s License Number
financial account number
☐ Biometrics
X Other. Please list:Medical history of the
student.

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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

g. List the specific authority to collect SSN or these other SPII elements.
USCG has the authority to collect this information in order to administer the Coast Guard Academy
under 14 U.S.C § § 181-200.

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.
Applicant information is used to filter and select appropriate candidates for admission to the CGA.
Medical information is needed to evaluate their ability to meet the strict standards for admission.

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.
Privacy Act statement on the form.

☐ 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?
X Electronic. Please describe the IT system that will
store the data from the form.
Academy Information System (ACADIS) secure
unclassified .edu network

X Scanned forms (completed forms are scanned into
an electronic repository). Please describe the
electronic repository.
ACADIS secure unclassified .edu network

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

X Manually (data elements manually entered). Please
describe.
Data from the application will be reviewed by USCGA
personnel.

☐ Automatically. Please describe.
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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

Click here to enter text.
c. How would a user
X By a unique identifier.2 Please describe. If
search the
information is retrieved by personal identifier, please
information
submit a Privacy Act Statement with this PTA.
submitted on the
Name
forms, i.e., how is the
☐ By a non-personal identifier. Please describe.
information
retrieved?
Records are destroyed immediately following the conclusion
d. What is the records
of the program.
retention
schedule(s)? Include
the records schedule
number.
Program manager personally destroys the record by USCG
e. How do you ensure
approved means after use.
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?
☐ Yes, information is shared with other DHS components or offices. Please describe.
Click here to enter text.
X Yes, information is shared external to DHS with other federal agencies, state/local
partners, international partners, or non-governmental entities. Please describe.
Information would be shared with emergency medical personnel and screened medical
contractors if a student is injured.

☐ No. Information on this form is not shared outside of the collecting office.

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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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

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

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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:

Robert Herrick

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

June 20, 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.)

June 27, 2017

X Yes. Please include it with this PTA
submission.
USCG Privacy will work with the program to update
the PAS with SORNs authorized for this collection.

☐ No. Please describe why not.
Click here to enter text.

Component Privacy Office Recommendation:
Academy Introduction Mission (AIM) Medical Release Form gives students accepted to and attending the
summer AIM program the ability to receive medical clearance from their primary care physician and for
parents to release liability for personal injury while their son or daughter attends the AIM program.
The AIM Medical Release Form collects name, date of birth, and medical history from the student and
name, address, telephone number and email address from the Parent/Legal Guardian. The form also
collects the name, title, address, telephone number, and fax number from the Examiner.
DHS/USCG/PIA-013, DHS/ALL/PIA-006, DHS/USCG-014 and DHS/USCG-027 provide coverage for
this collection.

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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:

Riley Dean

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

1145858
July 19, 2017
July 19, 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.
X Privacy Act Statement required.
X Privacy Impact Assessment (PIA) required.
X System of Records Notice (SORN) required.
☐ Specialized training required.
☐ Other. Click here to enter text.

DHS IC/Forms Review:

Choose an item.

Date IC/Form Approved Click here to enter a date.
by PRIV:
IC/Form PCTS Number: Click here to enter text.
Privacy Act
e(3) statement update is required.
Statement:
The DHS Privacy Office worked with USCG to complete an updated
Privacy Notice concurrently with this PTA submission.
PTA:
Choose an item.
Click here to enter text.
PIA:
System covered by existing PIA
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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: DHS/USCG/PIA-013 Academy
Information System
DHS/ALL/PIA-006 DHS General Contacts List
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-027 Recruiting Files,
August 10, 2011 76 FR 49494
DHS/USCG-014 Military Pay and Personnel, October 28, 2011 76 FR
66933
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.
USCG is submitting this PTA to discuss Form USCGA-AIM3, Academy Introduction
Mission (AIM) Medical Release Form, which is part of OMB control number 16250121. This information gathered from this form is used to obtain medical clearance
from primary care physician and for parents to release liability for personal injury
while their son or daughter attends the U.S. Coast Guard Academy for the Academy
Introduction Mission (AIM) program, a one-week summer orientation which allows
select rising high school seniors to experience cadet life at the academy and is
designed to recruit the future officers of the U.S. Coast Guard. The form gives
students accepted to and attending the summer AIM program the ability to receive
medical clearance/care.
The form collects the student’s name, gender, date of birth, and medical
history/information. It also collects parent/legal guardian’s name, address,
telephone number, and email address. The following information is collected from
physician/examiner: name, title, address, telephone number, and fax number. The
information from the form is stored in the Academy Information System (ACADIS),
and retrieved by the student’s name. This information may be shared with
emergency medical personnel and screened medical contractors if a student is
injured during their time at the AIM program. All information is destroyed
immediately following the conclusion of the summer program.
The DHS Privacy Office finds that PIA and SORN coverage are required for this
information collection.

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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

PIA coverage for the information about the student is provided by DHS/USCG/PIA013 Academy Information System (AIS), which describes the Academy information
system (ACADIS) transactional database system that provides an information
resource for the management of the academy educational environment, including
the training and development of all future Coast Guard officers. PIA coverage for the
collection of information about the parents of the student and the
physician/examiner is provided by DHS/ALL/PIA-006 DHS General Contacts List,
which outlines risks of DHS operations/projects that collect a minimal amount of
contact information in order to perform various administrative tasks.
SORN coverage is provided by DHS/USCG-014 Military Pay and Personnel and
DHS/USCG-027 Recruiting Files.
The DHS Privacy Office is working with USCG to complete an updated Privacy Notice
concurrently with this PTA submission.

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Version number: 04-2016