Privacy Impact Assessment

PRIVACY IMPACT ASSESSMENT (PIA)
PRESCRIBING AUTHORITY: DoD Instruction 5400.16, "DoD Privacy Impact Assessment (PIA) Guidance". Complete this form for Department of Defense
(DoD) information systems or electronic collections of information (referred to as an "electronic collection" for the purpose of this form) that collect, maintain, use,
and/or disseminate personally identifiable information (PII) about members of the public, Federal employees, contractors, or foreign nationals employed at U.S.
military facilities internationally. In the case where no PII is collected, the PIA will serve as a conclusive determination that privacy requirements do not apply to
system.
1. DOD INFORMATION SYSTEM/ELECTRONIC COLLECTION NAME:

SECNAV 12306/1 Confirmation of Reasonable Accommodation Request Form
3. PIA APPROVAL DATE:

2. DOD COMPONENT NAME:

08/27/24

Department of the Navy
Office of Equal Employment Opportunity
SECTION 1: PII DESCRIPTION SUMMARY (FOR PUBLIC RELEASE)
a. The PII is: (Check one. Note: foreign nationals are included in general public.)
From members of the general public

From Federal employees and/or Federal contractors

From both members of the general public and Federal employees and/or
Federal contractors

Not Collected (if checked proceed to Section 4)

b. The PII is in a: (Check one)
New DoD Information System

New Electronic Collection

Existing DoD Information System

Existing Electronic Collection

Significantly Modified DoD Information System
c. Describe the purpose of this DoD information system or electronic collection and describe the types of personal information about individuals
collected in the system.

Information collected includes name, DoD ID number, telephone number, email address, mailing address, and limited medical information.
The collected information is used to support the Department of the Navy’s reasonable accommodation process available to civilian
employees and applicants for employment.
d. Why is the PII collected and/or what is the intended use of the PII? (e.g., verification, identification, authentication, data matching, mission-related use,
administrative use)

The information is used to determine the need for reasonable accommodations, type of reasonable accommodations needed, and to track
estimated/actual cost of the reasonable accommodation.
e. Do individuals have the opportunity to object to the collection of their PII?

Yes

No

(1) If "Yes," describe the method by which individuals can object to the collection of PII.
(2) If "No," state the reason why individuals cannot object to the collection of PII.

Completion of the form is voluntary. However, the agency may not be able to process or track the reasonable accommodation request
without the information.
f. Do individuals have the opportunity to consent to the specific uses of their PII?

Yes

No

(1) If "Yes," describe the method by which individuals can give or withhold their consent.
(2) If "No," state the reason why individuals cannot give or withhold their consent.

Individuals may consent to the use of their PII for the reasonable accommodation process by completing, signing and submitting the
SECNAV 12306/1 Confirmation of Reasonable Accommodation Request Form.
g. When an individual is asked to provide PII, a Privacy Act Statement (PAS) and/or a Privacy Advisory must be provided. (Check as appropriate and
provide the actual wording.)
Privacy Act Statement

Privacy Advisory

Not Applicable

Authority: 5 U.S.C. 301; 5 U.S.C. Chapters 11, 13, 29, 31, 33, 41, 43, 51, 53, 55, 61, 63, 72, 75, 83, 99; 5 U.S.C. 7201; 29 USC 791; 10
U.S.C. 136;
E.O. 9830, as amended; 29 U.S.C. 79; 29 C.F.R. 1614.601, EEO Group Statistics; 29 CFR 1630.14, Medical Examinations and Inquiries
Specifically Permitted; SECNAV Instruction 12713.14, Equal Employment Opportunity; and E.O. 9397 (SSN), as amended, and System of
Records Notice (SORN) N12293-1.
Purpose(s): To provide relevant officials with the information to track, monitor, review, and process requests for reasonable accommodation.
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Routine Uses(s): In addition to those disclosures generally permitted under 5 U.S.C. 552a(b) of the Privacy Act of 1974, as amended, these
records contained therein may specifically be disclosed outside the Department of Defense (DoD) as a routine use pursuant to 5 U.S.C.
552a(b)(3) as follows: To the appropriate officials for the purpose of processing or responding to the request for reasonable accommodation
and/or decisions related to such request. To officials and employees of the Equal Employment Opportunity Commission and/or other
appropriate third parties responsible for investigating or adjudicating any cases that may result from a reasonable accommodation request.
To unions recognized as exclusive bargaining representatives under the Civil Service Reform Act of 1978, 5 U.S.C. §§ 7111 and 7114, the
Merit Systems Protection Board, the Office of the Special Counsel, arbitrators, the Federal Labor Relations Authority, and other parties
responsible for the administration of the Federal labor-management program for the purpose of processing any corrective actions,
grievances, or conducting administrative hearings or appeals. To the Office of Personnel Management (OPM), Office of Workers'
Compensation, and Department of Veterans Affairs for the purpose of addressing civilian pay and leave, benefits, retirement deduction, and
any other obligations. To an employee's private treating physician and to medical personnel retained by the DON to provide medical services
in connection with an employee's health or physical condition related to employment. To the Occupational Safety and Health officials when
needed to perform their duties.
Disclosure: Completion of this form is voluntary; however, failure to provide the requested information may result in an inability to process
your reasonable accommodation request.
h. With whom will the PII be shared through data exchange, both within your DoD Component and outside your Component? (Check all that apply)

Within the DoD Component

Department of the Navy (DON), Office of Equal
Employment Opportunity (EEO); EEO Leaders and
Specify.
Practitioners within the DON's subordinate commands;
Authorized Navy and USMC HR personnel

Other DoD Components

Specify.

Other Federal Agencies

Specify.

State and Local Agencies

Specify.

Contractor (Name of contractor and describe the language in
the contract that safeguards PII. Include whether FAR privacy
clauses, i.e., 52.224-1, Privacy Act Notification, 52.224-2,
Privacy Act, and FAR 39.105 are included in the contract.)

Specify.

Other (e.g., commercial providers, colleges).

Specify.

OPM

i. Source of the PII collected is: (Check all that apply and list all information systems if applicable)
Individuals

Databases

Existing DoD Information Systems

Commercial Systems

Other Federal Information Systems

j. How will the information be collected? (Check all that apply and list all Official Form Numbers if applicable)
E-mail

Official Form (Enter Form Number(s) in the box below)

Face-to-Face Contact

Paper

Fax

Telephone Interview

Information Sharing - System to System

Website/E-Form

Other (If Other, enter the information in the box below)

SECNAV 12306/1 Confirmation of Reasonable Accommodation Request Form
k. Does this DoD Information system or electronic collection require a Privacy Act System of Records Notice (SORN)?
A Privacy Act SORN is required if the information system or electronic collection contains information about U.S. citizens or lawful permanent U.S. residents that
is retrieved by name or other unique identifier. PIA and Privacy Act SORN information must be consistent.
Yes

No

If "Yes," enter SORN System Identifier

N12293-1

SORN Identifier, not the Federal Register (FR) Citation. Consult the DoD Component Privacy Office for additional information or http://dpcld.defense.gov/
Privacy/SORNs/

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or
If a SORN has not yet been published in the Federal Register, enter date of submission for approval to Defense Privacy, Civil Liberties, and Transparency
Division (DPCLTD). Consult the DoD Component Privacy Office for this date
If "No," explain why the SORN is not required in accordance with DoD Regulation 5400.11-R: Department of Defense Privacy Program.

l. What is the National Archives and Records Administration (NARA) approved, pending or general records schedule (GRS) disposition authority
for the system or for the records maintained in the system?
(1) NARA Job Number or General Records Schedule Authority.

DAA-GRS-2017-0007-0001

(2) If pending, provide the date the SF-115 was submitted to NARA.

(3) Retention Instructions.

Destroy three years after employee separation from the agency or three years after all administrative or judicial proceedings are concluded,
whichever is later.
m. What is the authority to collect information? A Federal law or Executive Order must authorize the collection and maintenance of a system of
records. For PII not collected or maintained in a system of records, the collection or maintenance of the PII must be necessary to discharge the
requirements of a statue or Executive Order.
(1) If this system has a Privacy Act SORN, the authorities in this PIA and the existing Privacy Act SORN should be similar.
(2) If a SORN does not apply, cite the authority for this DoD information system or electronic collection to collect, use, maintain and/or disseminate PII.
(If multiple authorities are cited, provide all that apply).
(a) Cite the specific provisions of the statute and/or EO that authorizes the operation of the system and the collection of PII.
(b) If direct statutory authority or an Executive Order does not exist, indirect statutory authority may be cited if the authority requires the
operation or administration of a program, the execution of which will require the collection and maintenance of a system of records.
(c) If direct or indirect authority does not exist, DoD Components can use their general statutory grants of authority (“internal housekeeping”) as
the primary authority. The requirement, directive, or instruction implementing the statute within the DoD Component must be identified.

5 U.S.C. 301; 5 U.S.C. Chapters 11, 13, 29, 31, 33, 41, 43, 51, 53, 55, 61, 63, 72, 75, 83, 99; 5 U.S.C. 7201; 29 USC 791; 10 U.S.C. 136;
E.O. 9830, as amended; 29 U.S.C. 79; 29 C.F.R. 1614.601, EEO Group Statistics; 29 CFR 1630.14, Medical Examinations and Inquiries
Specifically Permitted; SECNAV Instruction 12713.14, Equal Employment Opportunity; and E.O. 9397 (SSN), as amended, and System of
Records Notice (SORN) N12293-1.
n. Does this DoD information system or electronic collection have an active and approved Office of Management and Budget (OMB) Control
Number?
Contact the Component Information Management Control Officer or DoD Clearance Officer for this information. This number indicates OMB approval to
collect data from 10 or more members of the public in a 12-month period regardless of form or format.
Yes

No

Pending

(1) If "Yes," list all applicable OMB Control Numbers, collection titles, and expiration dates.
(2) If "No," explain why OMB approval is not required in accordance with DoD Manual 8910.01, Volume 2, " DoD Information Collections Manual:
Procedures for DoD Public Information Collections.”
(3) If "Pending," provide the date for the 60 and/or 30 day notice and the Federal Register citation.

OMB Control Number: OMB 0703-0063
Expiration: XX XXXXXXX 2025

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SECTION 2: PII RISK REVIEW
a. What PII will be collected (a data element alone or in combination that can uniquely identify an individual)? (Check all that apply)
Biometrics

Birth Date

Child Information

Citizenship

Disability Information

DoD ID Number

Driver's License

Education Information

Emergency Contact

Employment Information

Financial Information

Gender/Gender Identification

Home/Cell Phone

Law Enforcement Information

Legal Status

Mailing/Home Address

Marital Status

Medical Information

Military Records

Mother's Middle/Maiden Name

Name(s)

Official Duty Address

Official Duty Telephone Phone

Other ID Number

Passport Information

Personal E-mail Address

Photo

Place of Birth

Position/Title

Race/Ethnicity

Rank/Grade

Protected Health Information (PHI)1
Religious Preference

Records

Security Information

Work E-mail Address

If Other, enter the information in the box below

Social Security Number (SSN) (Full or in any
form)

(a) Employment information: SF-172, Application for Federal Employment, Job Experience, Training, Performance Plans, Promotions,
Reassignments, Adverse and Disciplinary actions;
(b) Education Information: DG-05 School Transcript, DG15-Employee Application, Certifications and Licensing;
(c) Other ID Number: Internal Employee ID Number, Manpower (TFMMS or TFSMS) Billet Number;
(d) Benefits Information: SF-2810 Notice of change in health and pay benefits, entitlements, SF-1152 Designation of Beneficiary, and
Separation, Retirement;
(e) Emergency Contact Information: Name, relationship, address, phone, email.
(f) Financial Information: TSP Rate, TSP Dollar Amount, Annual Salary (Basic, Locality, Adjusted), Awards/Bonus', and Monetary
Settlement Agreements.
(g) Disability Information: SF-256, Self-Identification of Disability; collects Name, Date of Birth, SSN, and Disability Code.
If the SSN is collected, complete the following questions.
(DoD Instruction 1000.30 states that all DoD personnel shall reduce or eliminate the use of SSNs wherever possible. SSNs shall not be used in spreadsheets,
hard copy lists, electronic reports, or collected in surveys unless they meet one or more of the acceptable use criteria.)
(1) Is there a current (dated within two (2) years) DPCLTD approved SSN Justification on Memo in place?
Yes

No

If "Yes," provide the signatory and date approval. If “No,” explain why there is no SSN Justification Memo.

SSN are not collected.

(2) Describe the approved acceptable use in accordance with DoD Instruction 1000.30 “Reduction of Social Security Number (SSN) Use within DoD”.

(3) Describe the mitigation efforts to reduce the use including visibility and printing of SSN in accordance with DoD Instructoin 1000.30, “Reduction of
Social Security Number (SSN) Use within DoD”.

(4) Has a plan to eliminate the use of the SSN or mitigate its use and or visibility been identified in the approved SSN Justification request?
If "Yes," provide the unique identifier and when can it be eliminated?
If "No," explain.
Yes

No

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b. What is the PII confidentiality impact level2?

Low

Moderate

High

1The definition of PHI involves evaluating conditions listed in the HIPAA. Consult with General Counsel to make this determination.
2Guidance on determining the PII confidentiality impact level, see Section 2.5 “Categorization of PII Using NIST SP 800-122.” Use the identified PII confidentiality impact level to apply the appropriate Privacy Overlay
low, moderate, or high. This activity may be conducted as part of the categorization exercise that occurs under the Risk Management Framework (RMF). Note that categorization under the RMF is typically
conducted using the information types described in NIST Special Publication (SP) 800-60, which are not as granular as the PII data elements listed in the PIA table. Determining the PII confidentiality impact level is
most effective when done in collaboration with the Information Owner, Information System Owner, Information System Security Manager, and representatives from the security and privacy organizations, such as the
Information System Security Officer (ISSO) and Senior Component Official for Privacy (SCOP) or designees.

c. How will the PII be secured?
(1) Physical Controls. (Check all that apply)
Cipher Locks

Closed Circuit TV (CCTV)

Combination Locks

Identification Badges

Key Cards

Safes

Security Guards

If Other, enter the information in the box below

(2) Administrative Controls. (Check all that apply)
Backups Secured Off-site
Encryption of Backups
Methods to Ensure Only Authorized Personnel Access to PII
Periodic Security Audits
Regular Monitoring of Users' Security Practices
If Other, enter the information in the box below

(3) Technical Controls. (Check all that apply)
Biometrics

Common Access Card (CAC)

DoD Public Key Infrastructure Certificates

Encryption of Data at Rest

Encryption of Data in Transit

External Certificate Authority Certificates

Firewall

Intrusion Detection System (IDS)

Least Privilege Access

Role-Based Access Controls

Used Only for Privileged (Elevated Roles)

User Identification and Password

Virtual Private Network (VPN)

If Other, enter the information in the box below

d. What additional measures/safeguards have been put in place to address privacy risks for this information system or electronic collection?

(a) HRCP only accessible from .mil, .gov., or authorized .edu authorized locations; validated via DISA.
(b) OCHR implemented CHRSAR form - multi-level authorization levels for approval to date; restricted to HR/Service Activities only. No
modifications to form/access; users required to submit "new"; validates annual IA and PII training is active (w/in last year).

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SECTION 3: RELATED COMPLIANCE INFORMATION
a. Is this DoD Information System registered in the DoD IT Portfolio Repository (DITPR) or the DoD Secret Internet Protocol Router Network
(SIPRNET) Information Technology (IT) Registry or Risk Management Framework (RMF) tool3?
Yes, DITPR

DITPR System Identification Number

Yes, SIPRNET

SIPRNET Identification Number

Yes, RMF tool

RMF tool Identification Number

DITPR: 13428
2588

No
If “No,” explain.

b. DoD information systems require assessment and authorization under the DoD Instruction 8510.01, “Risk Management Framework for DoD
Information Technology”.
Indicate the assessment and authorization status:
Authorization to Operate (ATO)

Date Granted:

ATO with Conditions

Date Granted:

Denial of Authorization to Operate (DATO)

Date Granted:

Interim Authorization to Test (IATT)

Date Granted:

3/3/2015

(1) If an assessment and authorization is pending, indicate the type and projected date of completion.

(2) If an assessment and authorization is not using RMF, indicate the projected transition date.

OCHR is presently in the process of renewing ATO; RMF/EMASS # 2588. Projected RMF transition date: XX XXX 20XX per the
transition
POA&M.
c. Does this DoD information system have an IT investment Unique Investment Identifier (UII), required by Office of Management and Budget (OMB)
Circular A-11?
Yes
If "Yes," Enter UII

No

007-000002452

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If unsure, consult the component IT Budget Point of Contact to obtain the UII

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3

Guidance on Risk Management Framework (RMF) tools (i.g., eMASS, Xacta, and RSA Archer) are found on the Knowledge Service (KS) at https://rmfks.osd.mil.

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SECTION 4: REVIEW AND APPROVAL SIGNATURES
Completion of the PIA requires coordination by the program manager or designee through the information system security manager and privacy representative at
the local level. Mandatory coordinators are: Component CIO, Senior Component Official for Privacy, Component Senior Information Security Officer, and
Component Records Officer.

Meena Farzanfar

(1) Title

Department of the Navy (DON),, Disability
Program Manager

DON, Office of Equal Employment
Opportunity (OEEO)

(3) Work
Telephone

(202) 685-6238

(4) DSN

(5) E-mail address

meena.farzanfar@navy.mil

(6) Date of Review

(7) Signature

a. Program Manager or
Designee Name

(2) Organization

b. Other Official (to be
used at Component
discretion)

(1) Title

(2) Organization

(3) Work
Telephone

(4) DSN

(5) E-mail address

(6) Date of Review

(7) Signature

c. Other Official (to be
used at Component
discretion)

(1) Title

(2) Organization

(3) Work
Telephone

(4) DSN

(5) E-mail address

(6) Date of Review

(7) Signature

d. Component Privacy
Officer (CPO)

Dawn Noriega

(1) Title

Privacy Coordinator

(2) Organization

(3) Work
Telephone

(202) 685-0412 EXT. 6533

(4) DSN

(5) E-mail address

dawn.noriega.ctr@us.navy.mil

(6) Date of Review

(7) Signature

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e. Component Records
Officer

Tonya Price

(1) Title

DON/AA, Directives and Records

Directives, Forms, and Information Collections
Manager

(3) Work
Telephone

(703) 693-9896

(4) DSN

(5) E-mail address

tonya.price1@navy.mil

(6) Date of Review

(7) Signature

(2) Organization

Management Division

f. Component Senior
Information Security
Officer or Designee
Name

(1) Title

(2) Organization

(3) Work
Telephone

(4) DSN

(5) E-mail address

(6) Date of Review:

(7) Signature

g. Senior Component
Official for Privacy
(SCOP) or Designee
Name

(1) Title

(2) Organization

(3) Work
Telephone

(4) DSN

(5) E-mail address

(6) Date of Review

(7) Signature

h. Component CIO
Reviewing Official
Name

(2) Organization

Steve Daughety
DON, Office of the Chief Information
Officer (OCIO)

(4) DSN

(6) Date of Review

09/01/21

(1) Title

DON Privacy Lead

(3) Work
Telephone

703-697-0045

(5) E-mail address

steve.daughety1@navy.mil

(7) Signature

Publishing: Only Section 1 of this PIA will be published. Each DoD Component will maintain a central repository of PIAs on the Component's public Web site.
DoD Components will submit an electronic copy of each approved PIA to the DoD CIO at: osd.mc-alex.dod-cio.mbx.pia@mail.mill.
If the PIA document contains information that would reveal sensitive information or raise security concerns, the DoD Component may restrict the
publication of the assessment to include Section 1.

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