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:
Form Title:
Component:

Form I-910

Application for Civil Surgeon Designation
U.S. Citizenship and
Immigration Services
(USCIS)

Office:

Field Operations
Directorate

IF COVERED BY THE PAPERWORK REDUCTION ACT:
Collection Title:
Form I-910, Application for Civil Surgeon Designation
OMB Control
1615-0114
OMB Expiration
May 31, 2020
Number:
Date:
Collection status:
Revision
Date of last PTA (if
August 28, 2019
applicable):
Name:
Office:

Phone:
Name:

PROJECT OR PROGRAM MANAGER
David P. Johnson
Field Operations
Title:
Adjudications Officer
Directorate
202-699-1514
Email:
David.P.Johnson@uscis.dhs.
gov

COMPONENT INFORMATION COLLECTION/FORMS CONTACT
Melanie Frank

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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

Office:

Phone:

OPS-PRA Compliance
Branch
202-527-4488

Title:

Management & Program
Analyst
Email:
Melanie.R.Frank2@uscis.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.
2020 Revision
USCIS is submitting this PTA update to document that Form I-910 will collect new
information. Form I-910 will now collect the county of practice for the clinic/practice;
the physician email address; confirmation as to whether the clinic’s physical address is
the same as the clinic’s mailing address; the mailing address of the clinic if it is not the
same as the physical address; the name of the school and graduation date of the civil
surgeon; confirmation of whether the medical license is in good standing; and
information about the interpreter.

USCIS is also deleting some questions from the form. Because the I-910 is solely
processed by the National Benefits Center, USCIS will remove the section indicating what
office granted the civil surgeon designation. USCIS will also remove the following section
from the form:
Part 2, Additional Office Information, questions 8-14:
8. Fees for Medical Examination
9. Acceptable Means of Payment
10. Accepted Medical Insurance Plans
12. Office Hours
13. Handicap Accessibility
14. Other

This section was deleted because it contained numerous questions that were not
necessary for adjudication of the Form I-910.
Form I-910, Application for Civil Surgeon Designation

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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

Section 212(a)(1)(A) of the Immigration and Nationality Act (Act) renders individuals
inadmissible if the individual is afflicted with the statutorily mentioned diseases or
medical conditions (these diseases and conditions include communicable diseases of
public health significance, failure to meet vaccination requirements, mental or physical
disorders with associated harmful behavior, or drug abuse or addiction). In order to
establish that the individual is admissible when seeking adjustment of status to a lawful
permanent resident (and in certain cases other aliens seeking an immigration benefit),
the individual must submit Form I-693, Report of Medical Examination and Vaccination
Record, that is completed by a civil surgeon, a USCIS-designated physician.

The statutory basis for the designation of civil surgeons and the medical examination of
aliens is contained in section 232 of the INA and 8 CFR 232.2. To be selected as a civil
surgeon, the physician has to demonstrate that he or she is a licensed physician with no
less than 4 years of professional experience. The National Benefits Center (NBC)
currently adjudicates all requests for civil surgeon designation, which are filed on Form
I-910, Application for Civil Surgeon Designation. Since March 11, 2014, adjudication of
Form I-910 has been centralized at NBC.

Relevant IT System
Form I-910 is processed and stored in the National Benefits Center Processing Workflow
Repository (NPWR).
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 to collect information in this form is set forth in Section 232 of the INA and
8 CFR 232.2.
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.
☐ DHS Employees

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

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

☐ DHS Contractors
☐ Other federal employees or contractors.

☒ 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
☒ Paper.
complete the form? Check
☒ Electronic. (ex: fillable PDF)
all that apply.
☐ Online web form. (available and submitted via
the internet)
Provide link:
https://www.uscis.gov/i-910
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.
To apply for civil surgeon designation, USCIS requires a civil surgeon to submit the following
information:
• A properly completed and signed Form I-910, with the required fee;
• A copy of a current medical license (for each state in which the physician seeks to
complete immigration medical examinations);
• A copy of each of the physician’s medical degrees, either as a Doctor of Medicine
(M.D.) or as a Doctor of Osteopathy (D.O.);
• Proof of four years of professional experience, excluding any time spent in postmedical school training. Evidence of professional experience includes, but is not
limited to, evaluations, certificates of completion, business tax returns or business
licenses (for self-employed physicians), or letters of employment verification; and

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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

•

Proof of U.S. citizenship, lawful permanent resident (LPR) status, or proof of
nonimmigrant status and employment authorization it the United States.

The Form I-910 collects the following required data about the applicant:
• Information about Civil Surgeon Designation (Civil Surgeon Identification Number),
period of designation, if USCIS has revoked designation, date of revocation, if
applicant has voluntarily terminated designation, date of termination
• First, middle and last name
• Other names used
• Date of birth
• Gender
• USCIS Online Account Number (if any)
• Alien Number
• Medical school and degree information (name of school, dates of attendance,
graduation date, degree)
• Medical license information (State or US territory, medical license number, date of
issue, date of expiration, if medical license is in good standing)
• Immigration status in the United States (date of last arrival in the US, Form I-94
number, passport number, country of issuance, expiration date for passport, current
nonimmigrant status, confirmation of possession of Employment Authorization
Document (EAD) and a copy of the EAD)
• Proof of four years of professional experience, including the names and contact
information of the physician’s employers

The Form I-910 collects the following required data about the Clinical Office:
• Name of Clinic/Practice
• Mailing address
• Physical address
• County of practice
• Telephone number
• Fax number
• Email address

The Form I-910 also collects the following optional data about the physician’s medical
practice where he or she intends to perform medical examinations:
• Email address
• Website address
• Languages spoken

Information collected about the interpreter includes:
• Full name
• Organization
• Mailing address
• Daytime telephone number

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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

•
•
•
•

Mobile telephone number
Email address
Interpreter’s certification
Signature of the interpreter

Information collected about the form preparer includes:
• Full name
• Organization
• Mailing address
• Preparer’s Certification
• Attorney State Bar Number
• Attorney or Accredited Representative USCIS Online Account Number
• Signature of the form preparer

This information will be included in the Civil Surgeon Locator (now Find a Doctor) to assist
applicants in searching for a civil surgeon.
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.

☐ 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: USCIS Online
Account Number
g. List the specific authority to collect SSN or these other SPII elements.
Section 232 of the INA and 8 CFR 232.2 allows USCIS to collect SPII in order to adjudicate
the Form I-910.
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.
This data collection is necessary to determine whether a physician meets the statutory
and regulatory requirements for civil surgeon designation. All documents are reviewed
to determine whether the physician has a currently valid medical license or and whether
the physician has had any action taken against him or her by the medical licensing
authority of the state.

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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

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.
Yes, a payment acceptance or rejection notice is
provided by the Lockbox as well as an
acknowledgment of receipt notice from NBC is
provided. Furthermore, USCIS provides a Privacy
Notice to the individual on the form instructions
prior to collecting any information.
☐ 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

b. If electronic, how
does DHS input the
responses into the IT
system?
c. How would a user
search the
information
submitted on the
forms, i.e., how is the
information
retrieved?

store the data from the form.
Click here to enter text.
☒ Scanned forms (completed forms are scanned into
an electronic repository). Please describe the
electronic repository.
Scanned forms are stored in the National Benefits
Center Processing Workflow Repository (NPWR).
☒ Manually (data elements manually entered). Please
describe.
Data input by contractors and signature page is
scanned in.
☐ Automatically. Please describe.
Click here to enter text.
☒ By a unique identifier. 2 Please describe. If
information is retrieved by personal identifier, please
submit a Privacy Act Statement with this PTA.
Receipt numbers are generated with a “CSD”
prefix and uploaded into RAILS, and a unique CS
Identification Number (CSID) is generated for
each civil surgeon applicant.

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

☐ By a non-personal identifier. Please describe.
Click here to enter text.
Paper files are stored for 35 years at Harrisonburg
(HBG) in accordance with DAA-0566-2014-0001.

d. What is the records
retention
schedule(s)? Include
the records schedule
number.
e. How do you ensure
Harrisonburg personnel are responsible for ensuring
that records are
the records are disposed of once the 35 year records
disposed of or deleted
retention schedule has been met.
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.
USCIS does not routinely share information with other DHS components to
designate physicians as civil surgeons. However, in the event USCIS suspects a
physician of fraud, USCIS will forward the case to ICE for potential criminal
investigation.
☒ Yes, information is shared external to DHS with other federal agencies, state/local
partners, international partners, or non-governmental entities. Please describe.
USCIS does not routinely share information with external components. However,
USCIS may share this information with the Department of Health and Human
Services (HHS) during the course of the civil surgeon application process as
required by law and pursuant to Routine Use Q in the DHS/USCIS-007 Benefits
Information System SORN.

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

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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

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:

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.)

Amanda Hoffmaster
January 14, 2020
January 16, 2020

☒ Yes. Please include it with this PTA
submission.
We are updating the Privacy Notice to include
the myUSCIS PIA.
☐ No. Please describe why not.
Click here to enter text.

Component Privacy Office Recommendation:
Please include recommendation below, including what existing privacy compliance
documentation is available or new privacy compliance documentation is needed.
The USCIS Office of Privacy recommendation is to designate Form I-910 as a privacy
sensitive form with coverage under the following:
PIA
•
•

DHS/USCIS/PIA-067 Civil Surgeon Designation, which covers the information
collected through the Form I-910, used, and maintained by the respective IT
systems.
DHS/USCIS/PIA-064 myUSCIS, which covers the Find a Civil Surgeon locator.

SORN
• DHS/USCIS-007 Benefits Information System SORN, which USCIS updated to cover
the collection, use, and maintenance of civil surgeon data

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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:

Jamie Huang

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

0010470
January 22, 2020
January 22, 2023

DESIGNATION

Privacy Sensitive IC or
Form:

Yes If “no” PTA adjudication is complete.

DHS IC/Forms Review:

Choose an item.

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 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:
OCC is currently reviewing the Privacy Notice
PTA:
Choose an item.
Click here to enter text.
PIA:
System covered by existing PIA
If covered by existing PIA, please list:

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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

•
•

SORN:

DHS/USCIS/PIA-064 myUSCIS
DHS/USCIS/PIA-067 Civil Surgeon Designation

If a PIA update is required, please list: Click here to enter text.
System covered by existing SORN
If covered by existing SORN, please list:
• DHS/USCIS-007 - Benefits Information System October 19, 2016 81 FR
72069

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.
USCIS is submitting this PTA update to document that Form I-910 will collect new
information. Form I-910 will now collect the county of practice for the clinic/practice;
the physician email address; confirmation as to whether the clinic’s physical address is
the same as the clinic’s mailing address; the mailing address of the clinic if it is not the
same as the physical address; the name of the school and graduation date of the civil
surgeon; confirmation of whether the medical license is in good standing; and
information about the interpreter. USCIS is also deleting some questions from the form.
Because the I-910 is solely processed by the National Benefits Center, USCIS will remove
the section indicating what office granted the civil surgeon designation.

The DHS Privacy Office agrees with USCIS Office of Privacy’s recommendation to designate
Form I-910 as a privacy sensitive form with coverage under the following PIAs and SORNs:
PIA
•

•

DHS/USCIS/PIA-067 Civil Surgeon Designation, covers the information collected
through the Form I-910, used, and maintained by the respective IT systems.
Specifically, physician’s information for the purpose of accrediting the physician as a
civil surgeon.
DHS/USCIS/PIA-064 myUSCIS, covers the “Find a Civil Surgeon” locator tool.

SORN
• DHS/USCIS-007 Benefits Information System SORN, covers the collection, use, and
maintenance of civil surgeon data
OCC is currently reviewing the Privacy Notice and PRIV requests a copy of the PN once it
has been finalized.

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