1625-new Cgrc-1130 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 – IC/Form

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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:
Form Title:
Component:

(CGRC-1130)
United States Coast Guard Prospect Questionnaire
DHS
Office: Coast
Coast Guard Recruiting
Guard
Command

IF COVERED BY THE PAPERWORK REDUCTION ACT:
Collection Title:
GOCOASTGUARD.COM CHAT NOW FORM
OMB Control
Number:
Collection status:

Name:
Office:
Phone:

Name:
Office:
Phone:

1625-TBD
Initiated

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

TBD
N/A

PROJECT OR PROGRAM MANAGER
Mauro Cooper
Coast Guard Recruiting
Title:
Chief, Marketing Division
Command
202-795-6823
Email:
Mauro.A.Cooper@uscg.mil

COMPONENT INFORMATION COLLECTION/FORMS CONTACT
Anthony Smith
Title: Information Collection Manager
CG-611
Email:
Anthony.D.Smith@uscg.mil
(202) 475-3532

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

SPECIFIC IC/Forms PTA QUESTIONS
1. Purpose of the Information Collection or Form
This information is collected to identify prospective members, assess eligibility, and
qualify candidates for service in the United States Coast Guard, and to manage, support,
and enhance the Coast Guard’s enlisted and commissioned officer recruiting mission.
The Prospect Questionnaire is the basic initial questionnaire for all prospective members
except those applying to the Coast Guard Academy. It allows for the initial eligibility
assessment to occur.

14 USC 468 authorizes the United States Coast Guard to recruit personnel for military
service. The information requested on the gocoastguard.com web site is collected in
accordance with Section 503 of Title 10, United States Code, and may only be used to
identify and process individuals interested in applying for enlistment or commission in
the United States Coast Guard or Coast Guard Reserve. Other legal authorities include
10 USC 504, 1475-1480; 14 USC 211, 350, 632; HSPD-12; and Executive Order 9397.
MOUs between Military Entrance Processing Command (MEPCOM) and USCG define
the PII requirements for processing USCG applicants.
Records are maintained at USCG Headquarters in Washington, DC and recruiting
offices.
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.)

☐ Yes
☐ No

☐ Members of the public
☐ 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.

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

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

d. 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: Online web form in development. In the

interim, primary means to complete is with a fillable PDF,
but hard copies are available if needed by the applicant.

e. What information will DHS collect on the form?
Name (last, first, middle), address (country, street, city, state, zip code), e-mail,
phone number, how you heard of the Coast Guard, program and component of
interest, citizen status and alien registration number (if applicable), Social Security
and Selective Service Numbers, ethnicity and race, date of birth, age, gender, birth
location (country, state, county, city), marital status and number of dependents,
height and weight, hair and eye color, education (highest attained, current or last
high school, school or community activities, current or last college, degree type,
major, grade point average (GPA), current education status, college credits, total

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

years of education), current employment status, driver’s license number, state, and
expiration, previous contact with a recruiter, current or prior military service
(including branch, years of service, service obligation remaining and separation
date, re-enlistment code, current or last paygrade or rank, job description), whether
previously rejected for service, previous Armed Services Vocational Aptitude
Battery (ASVAB) (if taken, when, score, location), prior criminal activity, pending
legal action, past drug use (how often, when last used, which substances), tattoos,
finances (history of overdue payments, bankruptcy, child support, alimony, current
debts), objection to carrying a weapon, religious constraints on 24/7 availability,
fear of the water and swimming ability, participation in various civic groups and
chronic medical conditions.
f. Does this form collect Social Security number (SSN) or other element that is standalone Sensitive Personally Identifiable Information (SPII)? Check all that apply.
☐ 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
☐ Other. Please list: Selective Service

number

g. List the specific authority to collect SSN or these other SPII elements.

Legal authorities include: 10USC 504, 1475-1480, 14USC211, 350,632, Homeland Security Presidential
Directive (HSPD) 12 and Executive Order 9397.

h. How will this information be used?

Data is used to make recruiting contacts with potential candidates, process candidates for aptitude
testing/physical exams, background checks, assess eligibility and ultimately progress to enlistment or
commissioning. Information is used to qualify enlisted and officer applicants for USCG service. Data is
aggregated for analysis and used to input in the USCG’s Direct Access HR system to initiate pay and
benefits for new members.

i. Are individuals
provided notice at the
time of collection by
DHS (Does the records

Privacy Threshold Analysis – IC/Form

☐ Yes. Please describe how notice is provided.

Collection notice / Privacy Act statement is prominently placed
on collection form.

☐ 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

subject have notice of
the collection or is
form filled out by third
party)?

3. How will DHS store the IC/form responses?
a. How will DHS store
☐ Paper. Please describe.
the original,
Recruiters will store any hard copy forms in the
applicant’s file.
completed IC/forms?
☐ Electronic. Please describe the IT system that will
store the data from the form.

Fillable PDF submissions will be maintained on the
CG Data Network, but are viewable only to recruiters
within the Recruiting Office to which the applicant is
assigned. Data will be manually in-put into USCG
Direct Access. Following completion of the online
web form, data will transmit automatically into Direct
Access.

b. If electronic, how
does DHS input the
responses into the IT
system?
c. How would a user
search the
information

☐ Scanned forms (completed forms are scanned into
an electronic repository). Please describe the
electronic repository.
Click here to enter text.

☐ Manually (data elements manually entered). Please
describe.
CGRC personnel must input data from hard copy or
fillable PDF into Direct Access.

☐ Automatically. Web entries automatically transferred

into Direct Access, pending development of online web form.

☐ By a unique identifier. 2 Please describe. By

individual’s name and zip code. Recruiters access records for
specific applicants to complete application process. If

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

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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

submitted on the
forms, i.e., how is the
information
retrieved?
d. What is the records
retention
schedule(s)? Include
the records schedule
number.

information is retrieved by personal identifier, please
submit a Privacy Act Statement with this PTA.
By a non-personal identifier. Please describe.

NARA retention schedule pending:

Electronic data for all applicants is retained through the end of the
second fiscal year after the year of collection. Data is archived
off-line for an additional two years. Information on selected
applicants (who are accessed) is forwarded for inclusion in the
Official Military Personnel File (OMPF).
For officer applicants, hard-copy information on non-selected
officer applicants is destroyed 6 months after deadline dates for
the class for which application is made. Hard copy information
collected for commissioning programs on selected applicants is
forwarded for inclusion in OMPF and destroyed 1 year from the
date of board by which considered.
For active duty enlisted applicants, Individual Personnel Applicant
Records for successful and unsuccessful applicants for enlistment
in the Coast Guard are destroyed 1 year after enlistment or
rejection.
For reserve enlisted applicants, , Individual Personnel Applicant
Records for successful and unsuccessful applicants for enlistment
in the Coast Guard are destroyed 2 years after enlistment or
rejection.
Records are disposed or deleted in accordance with
established business rules.

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?

☐ Yes, information is shared with other DHS components or offices. Please describe.
Information is shared with other DHS components or offices, including:

Internal to USCG at accession points for the purposes of completing hire transactions and
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

initiating personnel data records;
Internal to USCG with selection board members for determination of which applicants are
most suitable for selection as commissioned officers.
USCG personnel at accession and initial training points also receive reports via encrypted
email attachments, and as hard copy, hand carried reports and forms.

☐ Yes, information is shared external to DHS with other federal agencies, state/local
partners, international partners, or non-governmental entities. Please describe.
Data is shared with DOD (MEPCOM, Defense Manpower Data Center (DMDC)), and third
party contractor performing marketing support. The data may be extracted by government
personnel with Direct Access database access for official purposes.

☐ 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

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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:
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.)

Kenlinishia Tyler
March 3, 2017

March 24, 2017

X☐ Yes. Please include it with this PTA
submission.
☐ No. Please describe why not.
Click here to enter text.

Component Privacy Office Recommendation:
The Prospect Questionnaire Instructions form (CG-1130) collects name (last, first, middle), address
(country, street, city, state, zip code), e-mail, phone number, How you heard of the Coast Guard, program
and component of interest, citizen status and alien registration number (if applicable), Social Security and
Selective Service Numbers, ethnicity and race, date of birth, age, gender, birth location (country, state,
county, city), marital status and number of dependents, height and weight, hair and eye color, education
(highest attained, current or last high school, school or community activities, current or last college,
degree type, major, grade point average (GPA), current education status, college credits, total years of
education), current employment status, driver’s license number, state, and expiration, previous contact
with a recruiter, current or prior military service (including branch, years of service, service obligation
remaining and separation date, re-enlistment code, current or last paygrade or rank, job description),
whether previously rejected for service, previous Armed Services Vocational Aptitude Battery (ASVAB)
(if taken, when, score, location), prior criminal activity, pending legal action, past drug use (how often,
when last used, which substances), tattoos, finances (history of overdue payments, bankruptcy, child
support an alimony, current debts), objection to carrying a weapon, religious constraints on 24/7
availability, fear of the water and swimming ability, participation in various civic groups and chronic
medical conditions from members of the public and DHS employees, interested in a career in the Coast
Guard.

DHS/USCG/PIA-024 (Direct Access) and DHS/USCG-014 (Military Pay and Personnel System)
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

provides coverage for this collection.

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

Click here to enter text.

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

Click here to enter text.
Click here to enter a date.
Click here to enter a date.

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: Choose an item.

Click here to enter a date.
Date IC/Form
Approved by PRIV:
Click here to enter text.
IC/Form PCTS
Number:
Privacy Act
Choose an item.
Statement:
Click here to enter text.
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

PTA:

No system PTA required.
Click here to enter text.
PIA:
System covered by existing PIA
If covered by existing PIA, please list:
DHS/USCG/PIA-024 – Direct Access
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-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.
The DHS Privacy Office finds that the United States Coast Guard Prospect Questionnaire is a
privacy sensitive collection, requiring both PIA and SORN coverage. The questionnaire
collects a variety of personally identifiable information that is used to identify prospective
members, assess eligibility, and qualify candidates for service in the United States Coast
Guard, and to manage, support, and enhance the Coast Guard’s enlisted and commissioned
officer recruiting mission. Information collected includes Name (last, first, middle), address
(country, street, city, state, zip code), e-mail, phone number, how you heard of the Coast Guard,
program and component of interest, citizen status and alien registration number (if applicable),
Social Security and Selective Service Numbers, ethnicity and race, date of birth, age, gender, etc.
The DHS Privacy Office finds that PIA coverage is provided by DHS/USCG/PIA-024 – Direct
Access, which assesses the privacy risks associated with the Coast Guard’s use of PII in its
Direct Access system to conduct human resources and payroll functions. SORN coverage is
provided DHS/USCG-014 - Military Pay and Personnel System of Records Notice, which
outlines the Coast Guard’s collection and maintenance of records in order to administer the
USCG active duty, reserve, and retired active duty and retired reserve military pay and
personnel system.

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