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Privacy Impact Assessment Form
v 1.47.4
Status Draft

Form Number

F-50526

Form Date

Question

Answer

1

OPDIV:

CDC

2

PIA Unique Identifier:

P-7897016-318664

2a Name:

4/24/2019 12:25:04 PM

National Intimate Partner and Sexual Violence Survey 4.0
(NISVS 4.0)
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.

Implementation
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

Business Steward

POC Name

Marci-Jo Kresnow-Sedacca

POC Organization CDC
POC Email

Mjk1@cdc.gov

POC Phone

770.488.4753
New
Existing
Yes
No
June 13, 2019
Not Applicable

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11 Describe the purpose of the system.
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
about the specific data elements.)
Provide an overview of the system and describe the
13 information it will collect, maintain (store), or share,
either permanently or temporarily.
14 Does the system collect, maintain, use or share PII?

15

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

The National Intimate Partner and Sexual Violence Survey
(NISVS) information system collects information about
The data elements the system will be collecting on participants
include demographics such as age, gender, race, ethnicity, and
marital status. It also includes personal identifiable
information (PII) such as name, address, email, & phone
The NISVS information system will collect and store
information into a centralized data collection system. Potential
Study Participants will complete a Screener to determine
Yes
No
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
Race and Ethnicity
Age
User Credentials
Marital status
PINs
Employees
Public Citizens
16

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

Business Partners/Contacts (Federal, state, local agencies)
Vendors/Suppliers/Contractors
Patients
Other

17 How many individuals' PII is in the system?

18 For what primary purpose is the PII used?

500-4,999
For the Study Participants, name and address are collected to
distribute incentives; phone and email address collected if
survey to be completed over the phone; and demographics are
collected for study analysis. For Indirect contractor personnel,
name and email address is collected to assign the user
credentials.

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19

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

PII will not be used for any secondary purposes.

20 Describe the function of the SSN.

N/A

20a Cite the legal authority to use the SSN.

N/A

21

Identify legal authorities governing information use Public Health Service Act, Section 301, "Research and
and disclosure specific to the system and program.
Investigation" (42 U.S.C. 241).

22

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

Yes
No
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.

24 Is the PII shared with other organizations?
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.
26

Is the submission of PII by individuals voluntary or
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.

No number yet, TBD.
Yes
No
Study Participants are notified through the consenting
process. Indirect contractor personnel are notified when
assigned to the project if they have access to the management
system.
Voluntary
Mandatory
During the survey, Study Participants may opt-out of providing
their PII. Indirect contractor personnel cannot perform their
role in support of the study and accessing the system, if they
choose to opt-out.

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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
Study personnel will contact participants via email and phone
28 and/or data uses have changed since the notice at
number on record to notify and obtain consent when major
the time of original collection). Alternatively, describe changes occur to the system.
why they cannot be notified or have their consent
obtained.
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.

For Study Participants, the consenting process will provide the
information necessary if there are concerns about their PII.
Participants may contact Project Manager, Terry Green at
terrygreen@westat.com. Contractor personnel may contact
their supervisor if issues arise or the Project Manager, Terry
Green at terrygreen@westat.com.

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.

Study Participant data will be reviewed quarterly to ensure the
data's accuracy, integrity, and relevancy. In-direct contractor
personnel data will also be reviewed quarterly to ensure their
system access is accurate and relevant.
Users
Administrators

31

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

Developers

Contractors

Administrators need access to
administer and to provide systems
support.
Developers have access to the
Production site for systems support
(deployment of new site releases,
extraction and delivery of data,
In-direct contractors require access to
collect and assess the data.

Others
Describe the procedures in place to determine which Administrators and Developers granted access to data is based
32 system users (administrators, developers,
on the roles of users as authorized by the project manager and
contractors, etc.) may access PII.
the information system manager. Granulated rights at both
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.

Role based access control are in place to ensure the concept of
"least privilege" is implemented. Job function determines the
level of access and users are assigned only those rights
necessary to fulfill responsibilities for approved roles. Systemlevel audit controls safeguard and audit use.

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.

Privacy and Security awareness training is provided at onboarding; Human Subjects Protection training provided to all
personnel using the system. Refresher training in both Privacy
and Security and Human Subjects Protection is provided on an
annual basis.

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

Additional training for data collection, the use of data in
analyses, and other task-specific training is provided as
needed.

Do contracts include Federal Acquisition Regulation
36 and other appropriate clauses ensuring adherence to
privacy provisions and practices?

Yes
No

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Describe the process and guidelines in place with
37 regard to the retention and destruction of PII. Cite
specific records retention schedules.

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

Records are retained and disposed of in accordance with the
CDC Records Control Schedule (N1-442-09-1) and in
accordance with contractual agreement. Record copy of study
reports are maintained in the agency from two to three years
in accordance with retention schedules. Source documents for
computer are disposed of when they are no longer needed by
program officials. 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. Disposal methods include erasing
computer tapes, burning or shredding paper materials or
transferring records to the Federal Records Center when no
longer needed for evaluation and analysis. Records are
retained for 20 years; for longer periods if further study is
needed.
Administrative controls include a system security plan,
contingency plan, regular back up of files and storage of
backups off site, role-based security awareness training, least
privilege access enforced through Active Directory groups,
separate user and privileged accounts for administrators,
policies and procedures in place for retention and destruction
of PII, and a corporate incident response team and incident
response plans.
Technical controls include identification and authentication
using unique user IDs, passwords, and smart cards, use of
firewalls and intrusion detection/prevention systems, virus
scanning software on all computers, and a security information
and event management (SIEM) solution.
Physical controls include guards, identification badges, key
cards, and closed circuit TV.

39 Identify the publicly-available URL:
40 Does the website have a posted privacy notice?

HEALTHSAFETYSTUDY.ORG
Yes
No

40a

Is the privacy policy available in a machine-readable
format?

Yes

41

Does the website use web measurement and
customization technology?

Yes

No
No

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Technologies

Yes

Web beacons

No
Yes

Web bugs
Select the type of website measurement and
41a customization technologies is in use and if it is used
to collect PII. (Select all that apply)

Collects PII?

No

Session Cookies
Persistent Cookies

Yes
No
Yes
No
Yes

Other...

No

42

Does the website have any information or pages
directed at children under the age of thirteen?

Yes

43

Does the website contain links to non- federal
government websites external to HHS?

Yes

No

No

General Comments

OPDIV Senior Official
for Privacy Signature

signed by Jarell
Jarell Oshodi Digitally
Oshodi -S
Date: 2019.05.30 15:24:29
-S
-04'00'

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