1625-0087 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

Version number: 04-2016
Page 1 of 11

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:

CG-16700

Form Title:

North American Ice Service (NAIS) Customer Survey

Component:

U.S. Coast Guard (USCG)

Office:

International Ice Patrol

IF COVERED BY THE PAPERWORK REDUCTION ACT:
Collection Title:
North American Ice Service (NAIS) Customer Survey
OMB Control
Number:
Collection status:

Name:
Office:
Phone:

Name:

1625-0087
Extension

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

February 28, 2021
November 16, 2017

PROJECT OR PROGRAM MANAGER
LT Donald Rudnickas
International Ice Patrol
Title:
Ice Information Branch
Chief
860-271-2633
Email:
Donald.W.Rudnickas@uscg.
mil
COMPONENT INFORMATION COLLECTION/FORMS CONTACT
Anthony Smith

Privacy Threshold Analysis – IC/Form

Version number: 04-2016
Page 2 of 11

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

Office:
Phone:

CG-612
Title:
PRA Coordinator
202-475-3532
Email:
Anthony.D.Smith@uscg.mil
SPECIFIC IC/Forms PTA QUESTIONS

1. Purpose of the Information Collection or Form
As outlined in Safety of Life at Sea (SOLAS) Chapter V regulation 6 and 46 USC 80301-2
the U.S. Coast Guard is directed to maintain an ice patrol in the North Atlantic Ocean to
study and observe ice and current conditions. Ice dangers in the region shall be
broadcast by available means to trans-Atlantic and other passing vessels.
The Coast Guard International Ice Patrol, as directed by the Commandant of the Coast
Guard monitors the extent of the iceberg danger near the Grand Banks of Newfoundland
and provides iceberg warnings to the maritime community by broadcasting the
southeastern, southern, and southwestern limits of all known ice in two message
bulletins and one radio-facsimile chart each day.
Executive Order 12862 directs the United States Coast Guard (USCG) to conduct surveys
(both qualitative and quantitative) to determine the kind and quality of services our
customers want and expect, as well as their satisfaction with USCG’s existing services.
This survey will be limited to data collections that solicit strictly voluntary opinions and
will not collect information that is required or regulated.
46 U.S.C. § 80302 is the authority for this collection.

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

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

Version number: 04-2016
Page 3 of 11

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

☐ 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.
Click here to enter text.

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:

e. What information will DHS collect on the form?
Vessel name, call sign, home port, NAIS related information (e.g. bulletins, products,
navigation, etc.)

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
Privacy Threshold Analysis – IC/Form

Version number: 04-2016
Page 4 of 11

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

☐ Tax Identification Number
☐ Visa Number
☐ Passport Number
☐ Bank Account, Credit Card, or other
financial account number
☐ Other. Please list:

☐ 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, records subject fills out and submit 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?
☐ Electronic. Please describe the IT system that will
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.
Privacy Threshold Analysis – IC/Form

Version number: 04-2016
Page 5 of 11

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

A CG documentation specialist scans CG-16700 into a
secure file server on the USCG network.

.
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.
N/A

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.
All Surveys are kept in a secure electronic file server on
the USCG network. Information is retrieved by opening
each survey individually.

Records are kept permanently according to the
d. What is the records
Information and Life Cycle Management Manual
retention
(COMDTINST M5212.12A).
schedule(s)? Include
the records schedule
number.
Data Collection Ice Operations records are kept
e. How do you ensure
permanently. They are transferred to NARA five years
that records are
disposed of or deleted after the conclusion of the project or the publication of
the final record. (Ch. 1 to CONDTINST M5212.12A).
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?
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

Version number: 04-2016
Page 6 of 11

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

☐ 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.
The survey is forwarded to the Canadian Ice Service (CIS).

☐ 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

Version number: 04-2016
Page 7 of 11

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:

A.L. Craig

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

February 21, 2020

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.)

February 27, 2020
☐ Yes. Please include it with this PTA
submission.
X No. Please describe why not.
Information is not retrieved by a personal
identifier.

Component Privacy Office Recommendation:
As outlined in Safety of Life at Sea (SOLAS) Chapter V regulation 6 and 46 USC 80301-2 the
U.S. Coast Guard is directed to maintain an ice patrol in the North Atlantic Ocean to study
and observe ice and current conditions. Ice dangers in the region shall be broadcast by
available means to trans-Atlantic and other passing vessels.
The Coast Guard International Ice Patrol, as directed by the Commandant of the Coast
Guard monitors the extent of the iceberg danger near the Grand Banks of Newfoundland
and provides iceberg warnings to the maritime community by broadcasting the
southeastern, southern, and southwestern limits of all known ice in two message bulletins
and one radio-facsimile chart each day.
Executive Order 12862 directs the United States Coast Guard (USCG) to conduct surveys
(both qualitative and quantitative) to determine the kind and quality of services our
customers want and expect, as well as their satisfaction with USCG’s existing services. This
survey will be limited to data collections that solicit strictly voluntary opinions and will not
collect information that is required or regulated.
The North American Ice Service (NAIS) Customer Survey (CG-16700) is non-privacy
sensitive CG-Form and collects vessel name, call sign, home port, and NAIS related
Privacy Threshold Analysis – IC/Form

Version number: 04-2016
Page 8 of 11

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

information (e.g. bulletin, products, navigation, etc.). This collection is covered by
DHS/ALL/PIA-069 DHS Surveys, Interviews, and Focus Groups.

Privacy Threshold Analysis – IC/Form

Version number: 04-2016
Page 9 of 11

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:

Brian Pochatila

DHS Privacy Officer Approver (if applicable):
Workflow Number:
Date approved by DHS Privacy Office:
PTA Expiration Date

Riley Dean
00010725
February 27, 2020
February 27, 2023

DESIGNATION
Privacy Sensitive IC or
Form:

No 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.

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:
Privacy Notice is concurrently submitted and approved with this PTA.
PTA:
Choose an item.
Click here to enter text.
Privacy Threshold Analysis – IC/Form

Version number: 04-2016
Page 10 of 11

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

PIA:

System covered by existing PIA
If covered by existing PIA, please list: DHS/ALL/PIA-069 DHS Surveys,
Interviews, and Focus Groups.
If a PIA update is required, please list: Click here to enter text.
SORN:
Choose an item.
If covered by existing SORN, please list: Click here to enter text.
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 renewal for the North American Service (NAIS) Customer
Survey. USCG maintains an ice patrol in the North Atlantic Ocean to study and observe ice
and current conditions. Ice dangers in the region are then broadcast by available means to
trans-Atlantic and other passing vessels. USCG conducts this survey to determine the kind
and quality of services trans-Atlantic and other passing vessels want and expect, as well as
their satisfaction with USCG’s existing services. This survey is limited to data collections
that solicit strictly voluntary opinions and will not collect information that is required or
regulated. This form collects vessel name, call sign, home port, and NAIS related
information (e.g. bulletin, products, navigation, etc.). No PII is collected by the survey. The
information collected is voluntary, anonymous, and aggregated. Responses will not be
linked back to individuals. Individuals should not offer any unsolicited PII because it is not
needed. The NAIS Customer Survey will be shared with the Canadian Ice Service.
DHS Privacy agrees with USCG that the NAIS Customer Survey is a non-privacy sensitive as
no PII is collected from this survey. However, DHS/ALL/PIA-069 DHS Surveys, Interviews,
and Focus Groups discusses DHS and its Components periodically solicit voluntary
feedback from its employees, contractors, external stakeholders, and the general public
using surveys, interviews, and focus groups to improve DHS services and operations.
The Privacy Notice is concurrently submitted and approved with this PTA.

Privacy Threshold Analysis – IC/Form

Version number: 04-2016
Page 11 of 11