1625-0041 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

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Version number: 04-2016

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:

CG-16478

International Certificate on Inventory of Hazardous Materials
(Statement of Voluntary Compliance)
U.S. Coast Guard (USCG) Office:
CG-REG

IF COVERED BY THE PAPERWORK REDUCTION ACT:
Collection Title:
Various International Agreement Pollution Prevention Certificates
and Documents, and Equivalency Certificates
OMB Control
1625-0041
OMB Expiration
July 31, 2023
Number:
Date:
Collection status:
Extension
Date of last PTA (if
March 18, 2020
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

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

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,
1625-0041: “Various International Agreement Pollution Prevention Certificates and
Documents, and Equivalency Certificates.”
The purpose of the International Certificate on Inventory of Hazardous Materials
(Statement of Voluntary Compliance) (CG-16478) form is to certify that the vessel meets
certain Hong Kong International Convention for the Safe and Environmentally Sound
Recycling of Ships, 2009 requirements. The Coast Guard issues this form to document
compliance with the requirements.

CG-16478 includes the signature of the authorized official issuing or endorsing the
Certificate, port of issue (i.e., where authorizing official endorsed certificate), and vesselspecific information, such as—vessel name, distinctive numbers or letters, port of
registry, gross tonnage, and International Maritime Organization (IMO) number.

b. List the DHS (or Component) authorities to collect, store, and use this
information.
The authority for this collection is 33 U.S. Code 1901-1911 and 46 U.S. Code 3103, 3306,
3316 and 3703.
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

☒ Yes
☐ No

☐ Members of the public
☐ U.S. citizens or lawful permanent
residents

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

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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

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

d. How do individuals
complete the form? Check
all that apply.

☐ Non-U.S. Persons
☒ DHS Employees/Contractors (list
Components) USCG Authorizing Official
☐ 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/contractor. USCG Authorizing
Official.
☐ Other individual/entity/organization that is
NOT the record subject. Please describe.
Click here to enter text.

☒ 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?
CG-16478 includes the signature of the authorized official issuing or endorsing the
Certificate, port of issue (i.e., where authorizing official endorsed certificate), and vesselspecific information, such as—vessel name, distinctive numbers or letters, port of
registry, gross tonnage, and IMO number.
f. Does this form collect Social Security number (SSN) or other element that is
stand-alone Sensitive Personally Identifiable Information (SPII)? No.

Privacy Threshold Analysis – IC/Form

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Version number: 04-2016

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

☐ Social Security number
☐ Alien Number (A-Number)
☐ Tax Identification Number
☐ Visa Number
☐ Passport Number
☐ Bank Account, Credit Card, or other
financial account number
☐ Other. Please list:

☐ DHS Electronic Data Interchange
Personal Identifier (EDIPI)
☐ Social Media Handle/ID
☐ 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. 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 International Certificate on Inventory of Hazardous Materials
(Statement of Voluntary Compliance) form is to certify that the vessel meets certain
Hong Kong International Convention for the Safe and Environmentally Sound Recycling
of Ships, 2009 requirements. The Coast Guard issues this form to document compliance
with the requirements.
j.

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.
A Privacy Notice will be posted on the CG form.
☐ No.

3. How will DHS store the IC/form responses?

Privacy Threshold Analysis – IC/Form

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Version number: 04-2016

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

a. How will DHS store
the original,
completed IC/forms?

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?

2

d. What is the records
retention
schedule(s)? Include
the records schedule
number.
e. How do you ensure
that records are
disposed of or deleted

☐ Paper. Please describe.
Click here to enter text.
☐ 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 that the Coast Guard creates are
maintained in Marine Information for Safety and
Law Enforcement (MISLE) database.

☒ Manually (data elements manually entered). Please
describe.
A scanned record is uploaded to the vesselspecific file in MISLE.
☐ 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.
Click here to enter text.
☒ By a non-personal identifier. Please describe.
A search can be done using vessel-specific
information.
A record is retained for the life of the vessel; NARA
retention schedule number N1-026-05-015.
As records are maintained in the MISLE database,
disposal/deletion is in accordance with the business
rules for the database.

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

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Version number: 04-2016

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

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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Version number: 04-2016

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:
Concurrence from other Components
involved (if applicable):
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.)

A.L. Craig

April 18, 2023
N/A

May 9, 2023

☐ 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,
1625-0041: “Various International Agreement Pollution Prevention Certificates and
Documents, and Equivalency Certificates.”
The purpose of the International Certificate on Inventory of Hazardous Materials
(Statement of Voluntary Compliance) (CG-16478) form is to certify that the vessel meets
certain Hong Kong International Convention for the Safe and Environmentally Sound
Recycling of Ships, 2009 requirements. The Coast Guard issues this form to document
compliance with the requirements.

CG-16478 includes the signature of the authorized official issuing or endorsing the
Certificate, port of issue (i.e., where authorizing official endorsed certificate), and vesselspecific information, such as—vessel name, distinctive numbers or letters, port of registry,
gross tonnage, and IMO\ number.

Privacy Threshold Analysis – IC/Form

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Version number: 04-2016

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

Records related to CG-16478 are maintained in accordance with NARA retention schedule
number N1-026-05-015 and located in the facility or vessel-specific file in the Marine
Information for Safety and Law Enforcement (MISLE) database.

The International Certificate on Inventory of Hazardous Materials (Statement of Voluntary
Compliance) form is privacy sensitive-coverage is provided by is privacy sensitivecoverage is provided by DHS/USCG/PIA-008 (MISLE).

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Version number: 04-2016

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

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

0014457
May 10, 2023
May 10, 2026
Riley Dean

DESIGNATION

Privacy Sensitive IC or
Form:
Determination:

Privacy Act
Statement:
System PTA:
PIA:

SORN:

Yes If “no” PTA adjudication is complete.
☐ 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.

e(3) statement currently accurate.
PN submitted and approved.
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.
Choose an item.
If covered by existing SORN, please list: Click here to enter text.

Privacy Threshold Analysis – IC/Form

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Version number: 04-2016

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

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 renewing the Information Collection Request (ICR) titled, 1625-0041: “Various
International Agreement Pollution Prevention Certificates and Documents, and
Equivalency Certificates.” The purpose of the International Certificate on Inventory of
Hazardous Materials (Statement of Voluntary Compliance) (CG-16478) form is to certify
that the vessel meets certain Hong Kong International Convention for the Safe and
Environmentally Sound Recycling of Ships, 2009 requirements. The Coast Guard issues this
form to document compliance with the requirements.
CG-16478 includes the signature of the authorized official issuing or endorsing the
Certificate, port of issue (i.e., where authorizing official endorsed certificate), and vesselspecific information, such as—vessel name, distinctive numbers or letters, port of registry,
gross tonnage, and IMO\ number.
Records related to CG-16478 are maintained in accordance with NARA retention schedule
number N1-026-05-015 and located in the facility or vessel-specific file in the Marine
Information for Safety and Law Enforcement (MISLE) database.

DHS Privacy concurs that the International Certificate on Inventory of Hazardous Materials
(Statement of Voluntary Compliance) form is privacy sensitive requiring PIA coverage.
DHS/USCG/PIA-008 Marine Information for Safety and Law Enforcement (MISLE) captures
information required to support the Coast Guard's marine safety, security, environmental
protection and law enforcement programs. SORN coverage is not required because
information is not retrieved by unique identifiers.

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Version number: 04-2016