Pia

8. PIA.pdf

COVID-19 Pandemic Response, Laboratory Data Reporting

PIA

OMB: 0920-1299

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Privacy Impact Assessment Form
v 1.47.4
Status Draft

Form Number

F-74125

Form Date

Question

Answer

1

OPDIV:

CDC

2

PIA Unique Identifier:

P-3929910-878547

2a Name:

4/25/2019 10:45:40 AM

EIP Plus Messaging (EIP+M)
General Support System (GSS)
Major Application

3

Minor Application (stand-alone)

The subject of this PIA is which of the following?

Minor Application (child)
Electronic Information Collection
Unknown

3a

Identify the Enterprise Performance Lifecycle Phase
of the system.

Development
Yes

3b Is this a FISMA-Reportable system?

4

Does the system include a Website or online
application available to and for the use of the general
public?

5

Identify the operator.

6

Point of Contact (POC):

7

Is this a new or existing system?

8

Does the system have Security Authorization (SA)?

8b Planned Date of Security Authorization

No
Yes
No
Agency
Contractor
POC Title

Public Health Advisor

POC Name

Alvin Shultz

POC Organization NCEZID/DPEI
POC Email

fcu9@cdc.gov

POC Phone

404-639-7028
New
Existing
Yes
No
July 19, 2019
Not Applicable

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Emerging Infections Program (EIP) Plus Messaging (EIP+M) is a
surveillance system that provides transformation and
validation of Health Level Seven (HL7) messages to EIP state
partners. EIP+M provides transformation and validation of the
messages. The messages are made available for display to CDC
users and State Partners via a secure Web Portal.

11 Describe the purpose of the system.

EIP+M receives HL7 messages via the Message Validation,
Processing, and Provisioning System (MVPS) system. MVPS is a
separate CDC system with its own PIA. Messages are routed
from MVPS to Association of Public Health Labs (APHL), which
is a clearing house broker for HL7 messages. These messages
are sent to EIP+M by APHL. EIP+M provides transformation and
validation of the messages. The messages are made available
for display to CDC users and State Partners via a secure Web
Portal.

EIP+M contains lab results and patient demographics (DOB,
State, County, Age, Race, Sex, Zip Code) which is provided to
the states agencies to match the information submitted with
HL7 samples as testing results are returned. This is used to
properly identify the samples at the state agencies.

Describe the type of information the system will
collect, maintain (store), or share. (Subsequent
12
questions will identify if this information is PII and ask
The State Agencies have access to the EIP+M system directly
about the specific data elements.)
via secure URL, so user ID and password are needed for login.
These user credentials are stored permanently on the system.

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EIP+M is a surveillance system that receives HL7 messages via
the MVPS system. MVPS is a separate CDC system with its own
PIA. Messages are routed from MVPS to APHL, which is a
clearing house broker for HL7 messages. These messages are
sent to EIP+M by APHL. EIP+M provides transformation and
validation of the messages. The messages are made available
for display to CDC users and State Partners via a secure Web
Portal. The EIP+M system contains lab results and patient
demographics (DOB, State, County, Age, Race, Sex, Zip Code).
Data elements are secured by restricted access to the secure
Web Portal.

Provide an overview of the system and describe the
13 information it will collect, maintain (store), or share,
either permanently or temporarily.

The EIP+M system contains Patient Demographics ( DOB, State,
County, Age, Race, Sex, Zip Code). This information is collected
and provided to the state agencies to match the information
submitted with HL7 samples as testing results are returned.
This is used to properly identify the samples at the state
agencies. The data collected is used to geographically and
demographically locate the incidence of disease and
categorize it by the impacted geographic and demographic
groups. This information will be used for research purposes to
better inform the public on how to prevent and/or treat the
disease.
The State Agencies have access to the EIP+M system directly
via secure URL, so user ID and password are needed for login.
These user credentials are stored permanently on the system.
Data elements are secured by restricted access to the secure
Web Portal. Messages are maintained in a secure, encrypted
Structured Query Language Server database. Database
maintenance and backups are performed on a regularly
scheduled basis.

14 Does the system collect, maintain, use or share PII?

Yes
No

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15

Indicate the type of PII that the system will collect or
maintain.

Social Security Number

Date of Birth

Name

Photographic Identifiers

Driver's License Number

Biometric Identifiers

Mother's Maiden Name

Vehicle Identifiers

E-Mail Address

Mailing Address

Phone Numbers

Medical Records Number

Medical Notes

Financial Account Info

Certificates

Legal Documents

Education Records

Device Identifiers

Military Status

Employment Status

Foreign Activities

Passport Number

Taxpayer ID
DOB, State, County, Age, Race, Sex, Zip Code
Test/lab results
user credentials (User ID and Password)

Employees
Public Citizens
16

Business Partners/Contacts (Federal, state, local agencies)

Indicate the categories of individuals about whom PII
is collected, maintained or shared.

Vendors/Suppliers/Contractors
Patients
Other

17 How many individuals' PII is in the system?

18 For what primary purpose is the PII used?

19

Describe the secondary uses for which the PII will be
used (e.g. testing, training or research)

50,000-99,999
PII is used to geographically and demographically locate the
incidence of disease and categorize it by the impacted
demographic group. User credentials are needed for access.
This information will be used for research purposes to better
inform the public on how to prevent and/or treat the disease.

20 Describe the function of the SSN.

n/a

20a Cite the legal authority to use the SSN.

n/a

Public Health Service Act, Section 301, "Research and
Identify legal authorities governing information use Investigation," (42 U.S.C. 241); and Sections 304, 306 and 308(d)
21
which discuss authority to maintain data and provide
and disclosure specific to the system and program.
assurances of confidentiality for health research and related
activities (42 U.S.C. 242 b, k, and m(d)).
22

Are records on the system retrieved by one or more
PII data elements?

Yes
No

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Directly from an individual about whom the
information pertains
In-Person
Hard Copy: Mail/Fax
Email
Online
Other
Government Sources
23

Within the OPDIV
Other HHS OPDIV
State/Local/Tribal
Foreign
Other Federal Entities
Other

Identify the sources of PII in the system.

Non-Government Sources
Members of the Public
Commercial Data Broker
Public Media/Internet
Private Sector
Other
23a

Identify the OMB information collection approval
number and expiration date.

OMB Collection Approval 0920-0978, Expires 04/30/22
Yes

24 Is the PII shared with other organizations?

No
Within HHS

24a

Other Federal
Agency/Agencies
State or Local
Agency/Agencies

Identify with whom the PII is shared or disclosed and
for what purpose.

Disease Surveillance and Research
Private Sector
Describe any agreements in place that authorizes the
information sharing or disclosure (e.g. Computer
24b Matching Agreement, Memorandum of
N/A
Understanding (MOU), or Information Sharing
Agreement (ISA)).
24c

Describe the procedures for accounting for
disclosures

Describe the process in place to notify individuals
25 that their personal information will be collected. If
no prior notice is given, explain the reason.

N/A
Prior notice is not given to the individuals because the data is
originally provided to CDC by the State and Local Health
Departments, and any prior notice would be given by theses
entities. CDC collects this data whenever a case is reported by
a partner health agency, as required.

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26

Voluntary

Is the submission of PII by individuals voluntary or
mandatory?

Mandatory

Describe the method for individuals to opt-out of the
collection or use of their PII. If there is no option to
27
object to the information collection, provide a
reason.

There is no option to object to the collection of the
information. Local health regulations require these types of
confirmed laboratory test results to be reported. The
information collected by this system comes from State and
Local Public Health departments whenever a case is reported
by a partner health agency.

Describe the process to notify and obtain consent
from the individuals whose PII is in the system when
major changes occur to the system (e.g., disclosure
28 and/or data uses have changed since the notice at
the time of original collection). Alternatively, describe
why they cannot be notified or have their consent
obtained.

If there were major changes to the system, the program would
contact the state health departments. It would not be possible
to directly notify and obtain consent from the individuals
whose PII is in the system, because the system does not collect
any identifiable information that would allow CDC to contact
them.

Describe the process in place to resolve an
individual's concerns when they believe their PII has
29 been inappropriately obtained, used, or disclosed, or
that the PII is inaccurate. If no process exists, explain
why not.

There is not a redress process in place because of the nature of
the data that the system maintains; there is virtually no
identifiable data. The individual can contact the health facility
where the PII was collected, and any redress rights would be
exercised at the state and local levels where the information is
collected.

Describe the process in place for periodic reviews of
PII contained in the system to ensure the data's
30
integrity, availability, accuracy and relevancy. If no
processes are in place, explain why not.

The EIP+M Administrator reviews the overall Messages
received and exception logs each morning. Administrative staff
such as the EIP+M database and system administrator have
access to PII data through the management of the EIP+M
database and application servers. Data within the repository
will be obtained and reviewed nightly to ensure its integrity,
availability, accuracy and relevancy.

31

Identify who will have access to the PII in the system
and the reason why they require access.

Users

Users will have access to PII data for
Surveillance and research reporting.

Administrators

Administrators have access to PII data
in EIP+M for troubleshooting, database
and system management.

Developers
Contractors
Others

Accessing EIP+M data is provided via Role based access with
approval from the Business Steward (BS). Accessing PII data is
limited to the technical support staff who may incidentally
Describe the procedures in place to determine which view PII data while assisting internal users and troubleshoot
32 system users (administrators, developers,
issues in EIP+M.
contractors, etc.) may access PII.
Role based access, audit trail and traceability are implemented.
The administrator uses the system admin functionality to grant
access to the system based on the role of the user.

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Describe the methods in place to allow those with
33 access to PII to only access the minimum amount of
information necessary to perform their job.

The least privilege model and Role Based Access methods are
used to allow those with access to PII to only access the
minimum amount of information necessary to perform their
job. User access is limited to job function and information only
essential to the user function. Role based access, audit trail
and traceability are implemented. The administrator uses the
system admin functionality to grant access to the system
based on the role of the user.

Identify training and awareness provided to
personnel (system owners, managers, operators,
contractors and/or program managers) using the
34
system to make them aware of their responsibilities
for protecting the information being collected and
maintained.

All EIP+M personnel receive Security and Privacy Awareness
Training at least annually.

Describe training system users receive (above and
35 beyond general security and privacy awareness
training).

All EIP+M system users also receive role-based training on an
annual basis.

Do contracts include Federal Acquisition Regulation
36 and other appropriate clauses ensuring adherence to
privacy provisions and practices?
Describe the process and guidelines in place with
37 regard to the retention and destruction of PII. Cite
specific records retention schedules.

Yes
No
Records are retained and disposed of in accordance with the
CDC Scientific and Research Project Retention Schedule
N1-442-09-1. Personal identifiers may be deleted from records
when no longer needed in the study as determined by the
system manager, and as provided in the signed consent form,
as appropriate.
Administrative Controls:
Only authorized CDC staff, contractors, and guest researchers
have access to the data, all of whom receive the appropriate
Privacy and role-based trainings prior to access. No data will
be allowed to be downloaded to or to reside on a portable
device (e.g. laptops, thumb drives, storage media). PII is
secured in the system via Federal Information Security
Management Act (FISMA) compliant Management,
Operational, and Technical controls documented in the
systems security authorization package.

Describe, briefly but with specificity, how the PII will
38 be secured in the system using administrative,
technical, and physical controls.

This include Federal, HHS, and CDC specific Privacy, Risk
Assessment, and Incident Management Policies, as well as
annual PIA reviews.
Technical Controls:
Technical Controls include application level role based access
controls; servers audit and accountability requirements;
encryption of PII at rest and in transit; and adherence to
organizationally defined minimum security controls.
The implementation uses Advanced Encryption Standard,
which is a Federal Information Processing Standards compliant
for Server database encryption of the data. Column level
encryption is implemented to ensure PII data is secure.
Physical Controls:
Physical controls included security guards at gate to access
facility, card key access and physical locks to data rooms.

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General Comments

OPDIV Senior Official
for Privacy Signature

Beverly E.
Walker -S

Digitally signed by
Beverly E. Walker -S
Date: 2019.07.17 11:33:48
-04'00'

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File Typeapplication/pdf
File Modified2019-07-17
File Created2016-03-30

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