1625-0002 Privacy Threshold Analysis (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 12

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-2633

Form Title:

Application for Waiver and Waiver Order

Component:

U.S. Coast Guard (USCG)

Office:

CG-REG

IF COVERED BY THE PAPERWORK REDUCTION ACT:
Collection Title:
Applications for Vessel Inspection, Waiver, and Continuous Synopsis
Record
August 31, 2022
OMB Control
1625-0002
OMB Expiration
Number:
Date:
Collection status:
Extension
Date of last PTA (if
April 10, 2017
applicable):

Name:
Office:
Phone:

Name:
Office:
Phone:

PROJECT OR PROGRAM MANAGER
Mr. David Du Pont
CG-REG
Title:
Reg Dev Mgr
202-372-1497
Email:
David.A.DuPont@uscg.mil
COMPONENT INFORMATION COLLECTION/FORMS CONTACT
A.L. Craig
CG-6P
Title:
PRA Coordinator
202-475-3528
Email:
Albert.L.Craig@uscg.mil

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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

SPECIFIC IC/Forms PTA QUESTIONS
1. Purpose of the Information Collection or Form
a. Describe the purpose of the information collection or form.
The U.S. Coast Guard (USCG) is renewing the Information Collection Request (ICR) titled,
1625-0002: “Applications for Vessel Inspection, Waiver, and Continuous Synopsis
Record.”
The purpose of the form is to document an application for waiver. An application is
voluntary and is only submitted when a vessel owner/operator desires a waiver from the
navigation and vessel inspection requirements. The Coast Guard uses the information to
determine if a waiver can be issued.
The Application for Waiver and Waiver Order (CG-2633) contains the vessel name,
official vessel number, name of operator, vessel’s employment, vessel
description/identification data (if different from information on application), and waiver
request/justification, and duration data. CG-2633 also contains the date, title, and
signature of the applicant and the place, date, title, and signature of the USCG Issuing
Officer.
The Application for Waiver and Waiver Order (CG-2633) is uploaded into the facilityspecific file in the Marine Information for Safety and Law Enforcement system.
Records associated with this collection are maintained in accordance with NARA
retention schedule number N1-026-05-015.
b. List the DHS (or Component) authorities to collect, store, and use this
information.
46 U.S. Code 3306 and 33 CFR Part 19.06 are the authorities for this collection.

2. Describe the IC/Form

Privacy Threshold Analysis – IC/Form

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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

a. Does this form collect any
Personally Identifiable
Information” (PII1)?

☒ Yes
☐ No

b. From which type(s) of
individuals does this form
collect information?
(Check all that apply.)

☒ Members of the public
☒ U.S. citizens or lawful permanent
residents
☒ Non-U.S. Persons
☐ DHS Employees/Contractors (list
Components)
☐ 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/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?
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
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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

The Application for Waiver and Waiver Order (CG-2633) contains the vessel name,
official vessel number, name of operator, vessel’s employment, vessel
description/identification data (if different from information on application), and waiver
request/justification, and duration data. CG-2633 also contains the date, title, and
signature of the applicant and the place, date, title, and signature of the USCG Issuing
Officer.
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
☐ 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:
g. List the specific authority to collect SSN or these other SPII elements.
N/A
h. Is SSN necessary to carry out the functions of this form and/or fulfill
requirements of the information collection?
N/A
i. How will this information be used? What is the purpose of the collection?
The purpose of the form is to document an application for waiver. An application is
voluntary and is only submitted when a vessel owner/operator desires a waiver from the
navigation and vessel inspection requirements. The Coast Guard uses the information to
determine if a waiver can be issued.
j.

Are individuals
provided notice at the
time of collection by
DHS (Does the records
subject have notice of

☐ Yes. Please describe how notice is provided.
☒ No. Information is not retrieved by a personal
identifier.

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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

the collection or is
form filled out by
third party)?

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.
Forms the Coast Guard receive are maintained in
the Marine Information for Safety and Law
Enforcement (MISLE) database.
b. If electronic, how
does DHS input the
responses into the IT
system?

☒ Manually (data elements manually entered). Please
describe.
A scanned form is uploaded to the vessel-specific
file in MISLE.
☐ Automatically. Please describe.
Click here to enter text.

c. How would a user
search the
information
submitted on the
forms, i.e., how is the
information
retrieved?
d. What is the records
retention

☐ 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.
A search is done using vessel-specific information.
A record is retained for the life of the vessel; NARA
retention schedule number N1-026-05-015.

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
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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

schedule(s)? Include
the records schedule
number.
e. How do you ensure
As records are maintained in the MISLE database,
that records are
disposal/deletion is in accordance with the business
disposed of or deleted
rules of the database.
in accordance with
the retention
schedule?
f. Is any of this information shared outside of the original program/office?
☐ Yes, information is shared with other DHS components or offices. Please describe.
Click here to enter text.
☐ Yes, information is shared external to DHS with other federal agencies, state/local
partners, international partners, or non-governmental entities. Please describe.
Click here to enter text.
☒ 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.

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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:

A.L. Craig

Date submitted to Component Privacy
Office:
Concurrence from other Components
involved (if applicable):
Date submitted to DHS Privacy Office:

August 22, 2022

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.)

N/A
August 26, 2022
☐ Yes. Please include it with this PTA
submission.
☒ No. Please describe why not.
Information is not retrieved by a personal
identifier.

Component Privacy Office Recommendation:
Please include recommendation below, including what existing privacy compliance
documentation is available or new privacy compliance documentation is needed.
The U.S. Coast Guard (USCG) is renewing the Information Collection Request (ICR) titled,
1625-0002: “Applications for Vessel Inspection, Waiver, and Continuous Synopsis Record.”
The purpose of the form is to document an application for waiver. An application is
voluntary and is only submitted when a vessel owner/operator desires a waiver from the
navigation and vessel inspection requirements. The Coast Guard uses the information to
determine if a waiver can be issued.
The Application for Waiver and Waiver Order (CG-2633) contains the vessel name, official
vessel number, name of operator, vessel’s employment, vessel description/identification
data (if different from information on application), and waiver request/justification, and
duration data. CG-2633 also contains the date, title, and signature of the applicant and the
place, date, title, and signature of the USCG Issuing Officer.

Privacy Threshold Analysis – IC/Form

Version number: 04-2016
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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

The Application for Waiver and Waiver Order (CG-2633) is uploaded into the facilityspecific file in the Marine Information for Safety and Law Enforcement system.
CG-2633 is privacy sensitive-coverage is provided by DHS/USCG/PIA-008, Marine
Information for Safety and Law Enforcement.

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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:

Kattina Do

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

0023062
August 26, 2022
August 26, 2025

DESIGNATION
Privacy Sensitive IC or
Form:

Yes 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. Privacy Notice

Privacy Act
Statement:
System PTA:
PIA:

Choose an item.
Click here to enter text.
Choose an item.
Click here to enter text.
System covered by existing PIA
If covered by existing PIA, please list:
• DHS/USCG/PIA-008 Marine Information for Safety and Law
Enforcement (MISLE)
If a PIA update is required, please list: Click here to enter text.

SORN:
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.
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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

DHS Privacy Office Comments:
Please describe rationale for privacy compliance determination above.
The DHS Privacy Office finds that CG 2633 (Application for Waiver and Waiver
Order) is a privacy-sensitive collection. The application is used by vessel
owners/operators to request a waiver for navigation and vessel inspection
requirements. The form collects basic business contact information, which may
include the name and address of the vessel owner/operator, if it is owned/operated
by an individual.
The Privacy Office finds that PIA coverage is provided by DHS/USCG/PIA-008 Marine
Information for Safety and Law Enforcement (MISLE), which assess the privacy risks
associated with the Coast Guard’s use of PII in support of marine safety, security,
environmental protection and law enforcement programs. PRIV also finds that SORN
coverage is provided by DHS/USCG-013 - Marine Information for Safety and Law
Enforcement (MISLE), which outlines the Coast Guard’s collection and maintenance
of information in order to establish a safety, security and law enforcement
performance history of vessels, facilities, people and organizations engaged in
marine transportation, including enforcement action, that can be used to identify
and address safety, security and environmental risks and to establish vessel
eligibility for documentation as a U.S. flag vessel.
_________________________________________________________________________________________________________
Update 1:
USCG is submitting this updated PTA to discuss the Applications for Vessel
Inspection, Waiver, and Continuous Synopsis Record; Form CG-2633. The purpose of
the form is to document an application for waiver. An application is voluntary and is
only submitted when a vessel owner/operator desires a waiver from the navigation
and vessel inspection requirements.
The Application for Waiver and Waiver Order (CG-2633) contains the vessel name,
official vessel number, name of operator, vessel’s employment, vessel description/
identification data (if different from information on application), and waiver
request/justification, and duration data. CG-2633 also contains the date, title, and
signature of the applicant and the place, date, title, and signature of the USCG Issuing
Officer.
The DHS Privacy Office (PRIV) agrees that this form is privacy-sensitive, requiring
PIA coverage because PII is collected from members of the public.

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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

PRIV agrees with USCG Privacy that PIA coverage is provided by DHS/USCG/PIA-008
MISLE, which outlines the risks of capturing information required to support the
Coast Guard’s marine safety, security, environmental protection and law
enforcement programs.
PRIV agrees with USCG Privacy that SORN coverage is not required because
information is not retrieved by a personal identifier. However, SORN coverage is
provide by DHS/USCG-013 MISLE, which provides notice of this type of information
collection.
USCG is required to update the form with the Privacy Notice attached to this PTA.

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