PTA - Orphaned Well Site Plugging, Remediation, and Restoration Form

DI-4012 (9/2018)
U.S. Department of the Interior

U.S. Department of the Interior
PRIVACY THRESHOLD ANALYSIS

The DI-4012 Privacy Threshold Analysis (PTA) form helps Department of the Interior (DOI) Privacy
Officials determine whether a new or revised Privacy Impact Assessment (PIA) is required in
accordance with the E-Government Act, OMB policy, and the DOI PIA Guide, and identify other related
compliance requirements for the collection, maintenance, storage, use, processing, sharing or disposal of
personally identifiable information (PII) and any activities that may have privacy implications or
otherwise impact individual privacy. See the DOI PTA Guide for guidance on completing the PTA.
PTAs must be completed and submitted to the appropriate Bureau/Office Associate Privacy Officer for
review and compliance determination. Bureau/Office Associate Privacy Officers are responsible for
overseeing and managing PTAs for their organizations.

Section 1. General Information
Question

Response

A. Project, Program or System Name:

Orphaned Well Site Plugging, Remediation, and
Restoration Form

B. Bureau or Office:

Office of the Secretary
Policy and Environmental Management (PEM)

C. Program or Office:

Office of Environmental Policy and Compliance

D. Project/Program Manager or System
Owner:

Name: William Lodder
Title: Environmental Cleanup and Liability
Management Team Leader
Phone: 202-208-6128
E-mail: william_lodder@ios.doi.gov

E. Routing Information:

_X_ New PTA
___ Updated PTA
Date of Submission: December 2, 2021

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DI-4012 (9/2018)
U.S. Department of the Interior

Orphaned Well Site Plugging, Remediation, and Restoration Form
Privacy Threshold Analysis

Section 2. Project, Program or System Summary
Question
A. General description of the project, program
or system.

Response
The Interstate Oil and Gas Compact Commission
(IOGCC) has created a form to be used to collect data
from the states who intend to apply for Formula Grant
Funding. This is a one-time collection of information
associated with the award of formula grant funds for
orphaned well site plugging, remediation, and
restoration under the Bipartisan Infrastructure Law.

B. What is the technology or format used for
the Project, Program or System?

___ IT System
___ New Project or Program
___ Website
_X_ Web Form, Survey or Information Collection
___ Third-Party Website
___ Social Media Application
___ SharePoint
___ Mobile Application
___ Closed Circuit Television (CCTV)
___ Paper-based Collection
___ Other: Describe.

C. Does this project, program or system
involve a form, survey or information
collection?

_X_ Yes:
The IOGCC (non-government organization) has
developed the form in order to manage the collection of
data for states that will be applying for grant money.
___ No

D. Is Office of Management and Budget
(OMB) approval required for the collection?

_X_ Yes:
The U.S. Department of the Interior, Office of
Environmental Policy and Compliance, is requesting an
emergency clearance for information collection
requirements associated with the one-time collection of
information associated with the award of formula grant
funds for orphaned well site plugging, remediation, and
restoration under the Bipartisan Infrastructure Law.
OMB approval is pending.
___ No
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DI-4012 (9/2018)
U.S. Department of the Interior

Orphaned Well Site Plugging, Remediation, and Restoration Form
Privacy Threshold Analysis

Section 3. Personally Identifiable Information
Question

Response

A. What categories of individuals does the
Project, Program or System collect, maintain,
store, use, process, disseminate or dispose of
PII? Please select all that apply.

___ Federal employees
___ Contractors
___ Members of the public
___ Other: Describe.
_X_ This project, program or system does not collect,
maintain or process PII

B. What specific information about
individuals will be created, collected, used,
processed, maintained or disseminated?

C. Is information retrieved by a unique
identifier assigned to the individual?

The information collected on the form is associated with
the states.

___ Yes:
_X_ No

D. Is the information covered by a System of
Records Notice (SORN)?

___ Yes:

_X_ No
E. Does the Project, Program or System
collect or use Social Security Numbers
(SSNs)?

___ Yes:

Does this Project, Program or System receive
or share PII with any other internal DOI
programs or systems?

___ Yes:

.

_X_ No

_X_ No

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DI-4012 (9/2018)
U.S. Department of the Interior

Orphaned Well Site Plugging, Remediation, and Restoration Form
Privacy Threshold Analysis

Question

Response

G. Does this Project, Program or System
receive or share PII with any external (nonDOI) partners or systems?

___ Yes:

H. Is this external sharing pursuant to new
or existing information sharing agreement
(Memorandum of Understanding,
Memorandum of Agreement, Letters of
Intent, etc.)?

___ Yes:

_X_ No

_X_ No

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Orphaned Well Site Plugging, Remediation, and Restoration Form
Privacy Threshold Analysis

DI-4012 (9/2018)
U.S. Department of the Interior

Section 4. PTA Review and Recommendation
Question

Response

Privacy Compliance Determination:

_X_ PTA is sufficient at this time
___ Privacy Impact Assessment (PIA) required
___ Adapted PIA required
___ System of Records Notice (SORN) required
___ Notice of Proposed Rulemaking/Final Rule required
___ Computer Matching Notice required
___ Computer Matching Agreement required
___ Privacy Act Statement required
___ Privacy Notice required
___ Specialized role-based training required
___ Information sharing agreement required
___ Further privacy compliance review is required
___ Refer for Security Compliance Assessment
___ Refer for Information Collection Clearance Review
_X_ Refer for Records Review
___ Other:

Bureau Associate Privacy Officer Comments:

Associate Privacy Officer Name:
Bureau/Office:

The form does not collect personally identifiable
information. The information collected is associated
with the states. The information is going to be imported
to an Excel spreadsheet and saved on a shared drive.
Since this is an internal government operation and the
information is not be uploaded to a
designated/centralized system a PIA is not required.

Danna Mingo

DANNA
MINGO

Digitally signed by DANNA
MINGO
Date: 2021.12.02 18:16:43
-05'00'

OS Departmental Offices
DOI Privacy Office Comments

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