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Privacy Impact Assessment Form
v 1.21
Status

Form Number

Form Date

Question

Answer

1

OPDIV:

CDC

2

PIA Unique Identifier:

TBD

2a Name:

Acute Flaccid Myelitis: Patient Summary Form
General Support System (GSS)
Major Application

3

The subject of this PIA is which of the following?

Minor Application (stand-alone)
Minor Application (child)
Electronic Information Collection
Unknown

3a

Identify the Enterprise Performance Lifecycle Phase
of the system.
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

EPIDEMIOLOGIST

POC Name

Adriana Lopez

POC Organization NCIRD,DVD, EB
POC Email

ail7@cdc.gov

POC Phone

404.639.8369
New
Existing
Yes
No

June 1, 2016
Not Applicable

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8c

Briefly explain why security authorization is not
required

N/A

10

Describe in further detail any changes to the system
that have occurred since the last PIA.

N/A

11 Describe the purpose of the system.

Case Reporting for Acute Flaccid Myelitis

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.)

The Acute Flaccid Myelitis case reporting form collects: patient
information, Signs and symptoms of the patient, polio
vaccination history, Neuroradiographic findings, details of MRI ,
Cerebrospinal fluid (CSF) analysis, Electromyography (EMG),
Pathogen testing, Respiratory tract, stool, serum specimen
testing and collection.

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

The Acute Flaccid Myelitis (AFM) case reporting form is used to
conduct surveillance for AFM. Data collected through this
system will be used to determine baseline rates of AFM in the
United States and to monitor trends in disease over time.
Additionally, laboratory data collected will help with
identification of possible etiologic agents for AFM. Clinical
information will be used to describe cases, and polio
vaccination information will be used to determine if any of the
cases could be associated with polio. AFM surveillance will also
help with monitoring status of the US with regards to polio
elimination status.
Yes

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

Indicate the type of PII that the system will collect or
15
maintain.

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

County

Race

Other...

State

Other...

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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)

<100
Non-research public health surveillance of Acute Flaccid
Myelitis
N/A

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
Section 301 of Public Health Service Act (42 U.S.C. 241)
and disclosure specific to the system and program.

22

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

Yes
No
Published:

Identify the number and title of the Privacy Act
System of Records Notice (SORN) that is being used
22a
to cover the system or identify if a SORN is being
developed.

Published:
Published:
In Progress

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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.

0920-0009
Yes

24 Is the PII shared with other organizations?

No
Within HHS
Other Federal
Agency/Agencies
State or Local
Agency/Agencies

Identify with whom the PII is shared or disclosed and
24a
for what purpose.

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
The process for notifying individuals of the use of their
personal information is established by the state/local health
departments. Patient's physician collects information and
works with the state/local health department to notify the
patient that the data are collected to help monitor the disease
and add to the information that can help identify possible
etiologies for this illness.

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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
Patients can refuse to provide PII without any consequences.
collection or use of their PII. If there is no option to
27
They are given the choice to provide only the information they
object to the information collection, provide a
are comfortable providing.
reason.
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
CDC is unable to notify and obtain consent. CDC receives the
28 and/or data uses have changed since the notice at
data from the State/Local Health Department and do not have
the time of original collection). Alternatively, describe direct access to the patients' contact information.
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.

CDC does not have a process in place for AFM Surveillance to
address this issue. Any concerns of this nature would be
handled at the State/Local Health Department. We receive the
data from the State/Local Health Department and do not have
direct access to the patients.

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 Epidemiology Branch in the Division of Viral Diseases
maintains a database with information on what data each
member has that may contain PII. Information on how the data
are stored is reviewed annually to ensure data are being kept
securely and that the information is accurate.
Users
Administrators

31

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

Developers
Contractors

Users require access so that data can
be analyzed for review and summary.
Administrators require access to the
overall system for maintaining the
Developers of the system may require
access to PII if updates are made to
Contractors who are working on AFM
may require access to the PII if

Others
Describe the procedures in place to determine which Lead Epidemiologist for the project will determine which
32 system users (administrators, developers,
system users may access PII based on questions that need to
contractors, etc.) may access PII.
be addressed.
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.

Only the minimum amount of PII needed to do our jobs are
included in the system. If additional PII is sent, that information
is blacked out or redacted on paper copies and not included in
any electronic databases.

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.

Security and Privacy Awareness Training is conducted on an
annual basis to identify the responsibilities to protect PII.

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

The Epidemiology Branch in the Division of Viral Diseases also
has a policy available on our share drive about keeping PII
secure and the safeguards that need to be taken.

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

Yes
No
Scientific and Research Project Records Control Schedule,
Significant and or Secondary Research Records.

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

These records may be datasets, field records, and other
information necessary to understand a research project. They
may also be connected to other data through metadata,
indices, or other means. These records may include
background materials maintained by individual researchers
used to understand scientific advances, learn new techniques,
or to prepare for a new project.
Approved Records Control Schedule (N1-442-09-1, Item 2)
Authorized Disposition: Maintain at least eleven years, but no
longer than twenty years, after the retirement of the records
depending upon program need for scientific, legal, or business
reference.
Transfer to FRC is authorized in accordance with applicable
storage regulations of electronic records.

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

PII will be secured both physically and electronically. Physical
surveillance forms will be stored in locked cabinets within
employee badge-secured facilities; electronic data will be
saved in folders restricted to non-users, within passwordprotected computer systems.

REVIEWER QUESTIONS: The following section contains Reviewer Questions which are not to be filled out unless the user is an OPDIV
Senior Officer for Privacy.

Reviewer Questions
1

Are the questions on the PIA answered correctly, accurately, and completely?

Answer
Yes
No

Reviewer
Notes
2

Does the PIA appropriately communicate the purpose of PII in the system and is the purpose
justified by appropriate legal authorities?

Yes

Do system owners demonstrate appropriate understanding of the impact of the PII in the
system and provide sufficient oversight to employees and contractors?

Yes

No

Reviewer
Notes
3

No

Reviewer
Notes
4

Does the PIA appropriately describe the PII quality and integrity of the data?

Yes
No

Reviewer
Notes

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Reviewer Questions
5

Answer
Yes

Is this a candidate for PII minimization?

No

Reviewer
Notes
6

Does the PIA accurately identify data retention procedures and records retention schedules?

Yes
No

Reviewer
Notes
7

Are the individuals whose PII is in the system provided appropriate participation?

Yes
No

Reviewer
Notes
8

Does the PIA raise any concerns about the security of the PII?

Yes
No

Reviewer
Notes
9

Is applicability of the Privacy Act captured correctly and is a SORN published or does it need
to be?

Yes
No

Reviewer
Notes
10

Is the PII appropriately limited for use internally and with third parties?

Yes
No

Reviewer
Notes
11

Does the PIA demonstrate compliance with all Web privacy requirements?

Yes
No

Reviewer
Notes
12

Were any changes made to the system because of the completion of this PIA?

Yes
No

Reviewer
Notes

General Comments

OPDIV Senior Official
for Privacy Signature

Beverly E.
Walker -S

Digitally signed by Beverly E. Walker -S
DN: c=US, o=U.S. Government,
ou=HHS, ou=CDC, ou=People,
0.9.2342.19200300.100.1.1=100144034
3, cn=Beverly E. Walker -S
Date: 2016.05.26 14:41:34 -04'00'

HHS Senior
Agency Official
for Privacy

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