Pia

PRIVACY IMPACT ASSESSMENT (PIA)
For the
REASONABLE ACCOMMODATION (WHS FORM 9) Electronic Collection
WHS

SECTION 1: IS A PIA REQUIRED?
a. Will this Department of Defense (DoD) information system or electronic collection of
information (referred to as an "electronic collection" for the purpose of this form) collect,
maintain, use, and/or disseminate PII about members of the public, Federal personnel,
contractors or foreign nationals employed at U.S. military facilities internationally? Choose
one option from the choices below. (Choose (3) for foreign nationals).
(1) Yes, from members of the general public.
(2) Yes, from Federal personnel* and/or Federal contractors.
(3) Yes, from both members of the general public and Federal personnel and/or Federal contractors.
(4) No
* "Federal personnel" are referred to in the DoD IT Portfolio Repository (DITPR) as "Federal employees."

b. If "No," ensure that DITPR or the authoritative database that updates DITPR is annotated
for the reason(s) why a PIA is not required. If the DoD information system or electronic
collection is not in DITPR, ensure that the reason(s) are recorded in appropriate
documentation.
c. If "Yes," then a PIA is required. Proceed to Section 2.

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SECTION 2: PIA SUMMARY INFORMATION
a. Why is this PIA being created or updated? Choose one:
New DoD Information System

New Electronic Collection

Existing DoD Information System

Existing Electronic Collection

Significantly Modified DoD Information
System

b. Is this DoD information system registered in the DITPR or the DoD Secret Internet Protocol
Router Network (SIPRNET) IT Registry?
Yes, DITPR

Enter DITPR System Identification Number

Yes, SIPRNET

Enter SIPRNET Identification Number

No

c. Does this DoD information system have an IT investment Unique Project Identifier (UPI), required
by section 53 of Office of Management and Budget (OMB) Circular A-11?
No

Yes
If "Yes," enter UPI

If unsure, consult the Component IT Budget Point of Contact to obtain the UPI.

d. 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 should be consistent.

No

Yes
If "Yes," enter Privacy Act SORN Identifier

DWHS P49

DoD Component-assigned designator, not the Federal Register number.
Consult the Component Privacy Office for additional information or
access DoD Privacy Act SORNs at: http://www.defenselink.mil/privacy/notices/

or
Date of submission for approval to Defense Privacy Office
Consult the Component Privacy Office for this date.

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e. Does this DoD information system or electronic collection have an 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
Enter OMB Control Number

in process

Enter Expiration Date
No
f. Authority to collect information. A Federal law, Executive Order of the President (EO), or DoD
requirement must authorize the collection and maintenance of a system of records.
(1) If this system has a Privacy Act SORN, the authorities in this PIA and the existing Privacy Act
SORN should be the same.
(2) 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) Whenever possible, cite the specific provisions of the statute and/or EO that authorizes
the operation of the system and the collection of PII.
(b) If a specific statute or EO does not exist, determine if an indirect statutory authority can
be cited. An indirect 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) 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 should be identified.
29 U.S.C. § 791, Employment of Individuals with Disabilities; E.O. 13164, Requiring Federal Agencies to
Establish Procedures to Facilitate the Provision of Reasonable Accommodation; EEO MD-715, EEO
Reporting Requirements for Federal Agencies and DoD Directive 1020.1.

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g. Summary of DoD information system or electronic collection. Answers to these questions
should be consistent with security guidelines for release of information to the public.
(1) Describe the purpose of this DoD information system or electronic collection and briefly
describe the types of personal information about individuals collected in the system.
To document requests for reasonable accommodation(s), reasons for the request, and the time frame in
which a response is issued to job applicants and employees serviced by the Washington Headquarters
Services/Human Resources Directorate.
Job applicants and employees will be asked to provide their name, contact information, organization name,
reasonable accommodation requested, and reason for the request.

(2) Briefly describe the privacy risks associated with the PII collected and how these risks are
addressed to safeguard privacy.
Access is limited to staff members working within the reasonable accommodation program, equal
employment opportunity program, and office of general counsel.
Automated records are controlled by limiting physical access to terminals and by the use of computer access
cards. Work areas are controlled access requiring key cards. Security guards protect buildings. Staff
members complete annual Information Assurance and Privacy Act training.

h. With whom will the PII be shared through data exchange, both within your DoD Component and
outside your Component (e.g., other DoD Components, Federal Agencies)? Indicate all that apply.
Within the DoD Component.
Specify.

OGC, EEOP and supervisors within the employee's chain of command that
need to know about restrictions on the work environment or duties of the
employee.

Other DoD Components.

Specify.

Government officials investigating compliance with the ADA; and OSD

Other Federal Agencies.

Specify.

EEO

State and Local Agencies.

Specify.

First aid and safety personnel in the event that the employee requires
emergency treatment; state workers' compensation offices, and state second
injury funds.

Contractor (Enter name and describe the language in the contract that safeguards PII.)

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

Specify.

Workers' compensation insurance carriers

i. Do individuals have the opportunity to object to the collection of their PII?
Yes

No

(1) If "Yes," describe method by which individuals can object to the collection of PII.
The form states that completion is voluntary. Employees are encouraged to submit a Confirmation of
Request for Reasonable Accommodation (Enclosure 4) to the RAPM for the most expeditious processing.
However, the agency is responsible for responding to an employee's request whether it is or is not recorded
on the form.

(2) If "No," state the reason why individuals cannot object.

j. 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.
The form itself clearly states that it is used to document requests for reasonable accommodation(s) and the
outcome of such requests. It states that completion of the form is voluntary. Therefore, employees know
that if they do not want to have their personal information gathered for these purposes, he or she does not
have to complete the form.

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k. What information is provided to an individual when asked to provide PII data? Indicate all that
apply.
Privacy Act Statement

Privacy Advisory

Other

None

Describe AUTHORITY: 29 U.S.C. 791, 42 U.S.C. Chapter 126, 29 CFR Part 1630, E.O. 13163, E.O. 13164,
each
and DoD Directive 1020.1.
applicable
format.
PRINCIPAL PURPOSE(S): To document requests for reasonable accommodation(s) (regardless of
type of accommodation) and the outcome of such requests for employees of Washington
Headquarters Services/Human Resources Directorate serviced components with known physical and
mental impairments and applicants for employment with Washington Headquarters Services/Human
Resources Directorate serviced components. These records are covered by SORN DWHS P49:
http://dpclo.defense.gov/privacy/SORNs/component/osd/DWHSP49.html
ROUTINE USE(S): The DoD "Blanket Routine Uses" found at http://dpclo.defense.gov/privacy/
SORNs/blanket_routine_uses.html apply to this collection.
DISCLOSURE: Voluntary. However, failure to provide sufficient information may delay or prevent an
adequate basis to determine an appropriate
accommodation.

NOTE:
Sections 1 and 2 above are to be posted to the Component's Web site. Posting of these
Sections indicates that the PIA has been reviewed to ensure that appropriate safeguards are in
place to protect privacy.
A Component may restrict the publication of Sections 1 and/or 2 if they contain information that
would reveal sensitive information or raise security concerns.

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SECTION 3: PIA QUESTIONNAIRE and RISK REVIEW
a. For the questions in subparagraphs 3.a.(1) through 3.a.(5), indicate what PII (a data element
alone or in combination that can uniquely identify an individual) will be collected and describe
the source, collection method, purpose, and intended use of the PII.
(1) What PII will be collected?

Indicate all individual PII or PII groupings that apply below.

Name

Other Names Used

Social Security Number (SSN)

Truncated SSN

Driver's License

Other ID Number

Citizenship

Legal Status

Gender

Race/Ethnicity

Birth Date

Place of Birth

Personal Cell Telephone
Number

Home Telephone
Number

Personal Email Address

Mailing/Home Address

Religious Preference

Security Clearance

Mother's Maiden Name

Mother's Middle Name

Spouse Information

Marital Status

Biometrics

Child Information

Financial Information

Medical Information

Disability Information

Law Enforcement
Information

Employment Information

Military Records

Emergency Contact

Education Information

Other

If "Other," specify or Accommodation Requested; Reason for request; Time sensitivity concerns
explain any PII
grouping selected.

(2) What is the source for the PII collected (e.g., individual, existing DoD information
systems, other Federal information systems or databases, commercial systems)?
SD Form 09: CONFIRMATION OF REQUEST FOR REASONABLE ACCOMMODATION (Individual)

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(3) How will the information be collected? Indicate all that apply.

Paper Form

Face-to-Face Contact

Telephone Interview

Fax

Email

Web Site

Information Sharing - System to System
Other

(4) Why are you collecting the PII selected (e.g., verification, identification, authentication,
data matching)?
Verification.

(5) What is the intended use of the PII collected (e.g., mission-related use,
administrative use)?
Mission related and administrative. To document requests for reasonable accommodation(s) and the time
in which the agency responds to such requests.

b. Does this DoD information system or electronic collection create or derive new PII about
individuals through data aggregation? (See Appendix for data aggregation definition.)
Yes

No

If "Yes," explain what risks are introduced by this data aggregation and how this risk is mitigated.

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c. Who has or will have access to PII in this DoD information system or electronic
collection? Indicate all that apply.
Users

Developers

System Administrators

Contractors

Other

Access is limited to staff members working within the reasonable accommodation program, equal
employment opportunity program, and office of general counsel.

d. How will the PII be secured?
(1) Physical controls. Indicate all that apply.
Security Guards

Cipher Locks

Identification Badges

Combination Locks

Key Cards

Closed Circuit TV (CCTV)

Safes

Other

Automated records are controlled by limiting physical access to terminals and by the use of computer
access cards. Work areas are controlled access requiring key cards. Security guards protect
buildings. Staff members complete annual Information Assurance and Privacy Act training.

(2) Technical Controls. Indicate all that apply.
User Identification

Biometrics

Password

Firewall

Intrusion Detection System
(IDS)

Virtual Private Network (VPN)

Encryption

DoD Public Key Infrastructure
Certificates

External Certificate Authority
(CA) Certificate

Common Access Card (CAC)

Other

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(3) Administrative Controls. Indicate all that apply.
Periodic Security Audits
Regular Monitoring of Users' Security Practices
Methods to Ensure Only Authorized Personnel Access to PII
Encryption of Backups Containing Sensitive Data
Backups Secured Off-site
Other

Note: The Authorization to Operate (ATO) in 3.e is related to WHS ENTERPRISE
INFRASTRUCTURE

e. Does this DoD information system require certification and accreditation under the DoD
Information Assurance Certification and Accreditation Process (DIACAP)?
Yes. Indicate the certification and accreditation status:
Authorization to Operate (ATO)

Date Granted:

Interim Authorization to Operate (IATO)

Date Granted:

Denial of Authorization to Operate
(DATO)

Date Granted:

Interim Authorization to Test (IATT)

Date Granted:

20090105

No, this DoD information system does not require certification and accreditation.

f. How do information handling practices at each stage of the "information life cycle" (i.e.,
collection, use, retention, processing, disclosure and destruction) affect individuals' privacy?
An employee completes the form and submits it to either his or her supervisor, or the Reasonable
Accommodation Program Coordinator/Manager (RAPM). The RAPM stores the completed documents in both
electronic and hard copy form, as part of a case file. Information (no individual names) is collected and recorded
for reporting purposes. Destroy/Delete 3 years after employee separation from the agency, all appeals are
concluded, after superseded, or when no longer needed for reference.

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g. For existing DoD information systems or electronic collections, what measures have been put in
place to address identified privacy risks?
.Not applicable.

h. For new DoD information systems or electronic collections, what measures are planned for
implementation to address identified privacy risks?
.Automated records are controlled by limiting physical access to terminals and by the use of computer access
cards. Work areas are controlled access requiring key cards. Security guards protect buildings. Staff members
complete annual Information Assurance and Privacy Act training.

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SECTION 4: REVIEW AND APPROVAL SIGNATURES
Prior to the submission of the PIA for review and approval, the PIA must be coordinated by
the Program Manager or designee through the Information Assurance Manager and Privacy
Representative at the local level.

Program Manager or
Designee Signature

GRIFFITH.JOANNA.MARIA.12683963
37

Digitally signed by GRIFFITH.JOANNA.MARIA.1268396337
DN: c=US, o=U.S. Government, ou=DoD, ou=PKI, ou=WHS,
cn=GRIFFITH.JOANNA.MARIA.1268396337
Date: 2012.04.02 15:00:43 -04'00'

Name:

Jo-Anna Griffith

Title:

Human Resources Specialist (Reasonable Accommodation Coordinator)

Organization:

WHS/Human Resources Directorate

Work Telephone Number: (571) 372-4034
DSN:
Email Address:

[email protected]

Date of Review:

04/02/2012

Other Official Signature
(to be used at Component
discretion)
Name:
Title:
Organization:
Work Telephone Number:
DSN:
Email Address:
Date of Review:

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Other Official Signature
(to be used at Component
discretion)
Name:
Title:
Organization:
Work Telephone Number:
DSN:
Email Address:
Date of Review:
Component Senior
Information Assurance
Officer Signature or
Designee

KENNEDY.GEOR
GE.L.1200888908

Name:

George Lee Kennedy

Title:

SIAO

Organization:

WHS/EITSD

Digitally signed by
KENNEDY.GEORGE.L.1200888908
DN: c=US, o=U.S. Government, ou=DoD,
ou=PKI, ou=WHS,
cn=KENNEDY.GEORGE.L.1200888908
Date: 2012.05.16 09:38:30 -04'00'

Work Telephone Number: (571) 372-0201
DSN:
Email Address:

[email protected]

Date of Review:

05/16/2012

Component Privacy Officer BYRD.JOAN.
Signature
MARIE.1255778800
Name:

Joan Byrd

Title:

Privacy Analyst

Organization:

WHS/Enterprise Management

Digitally signed by BYRD.JOAN.MARIE.1255778800
DN: c=US, o=U.S. Government, ou=DoD, ou=PKI,
ou=WHS, cn=BYRD.JOAN.MARIE.1255778800
Date: 2012.05.15 07:47:13 -04'00'

Work Telephone Number: (571) 372-0900
DSN:
Email Address:

[email protected]

Date of Review:
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Component CIO Signature
(Reviewing Official)
Name:
Title:
Organization:
Work Telephone Number:
DSN:
Email Address:
Date of Review:

Publishing:
Only Sections 1 and 2 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: [email protected].
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 Sections 1
and 2.

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APPENDIX
Data Aggregation. Any process in which information is gathered and expressed in a summary form for
purposes such as statistical analysis. A common aggregation purpose is to compile information about
particular groups based on specific variables such as age, profession, or income.
DoD Information System. A set of information resources organized for the collection, storage, processing,
maintenance, use, sharing, dissemination, disposition, display, or transmission of information. Includes
automated information system (AIS) applications, enclaves, outsourced information technology (IT)-based
processes and platform IT interconnections.
Electronic Collection. Any collection of information enabled by IT.
Federal Personnel. Officers and employees of the Government of the United States, members of the
uniformed services (including members of the Reserve Components), and individuals entitled to receive
immediate or deferred retirement benefits under any retirement program of the United States (including
survivor benefits). For the purposes of PIAs, DoD dependents are considered members of the general public.

Personally Identifiable Information (PII). Information about an individual that identifies, links, relates or is
unique to, or describes him or her (e.g., a social security number; age; marital status; race; salary; home
telephone number; other demographic, biometric, personnel, medical, and financial information). Also,
information that can be used to distinguish or trace an individual's identity, such as his or her name; social
security number; date and place of birth; mother's maiden name; and biometric records, including any other
personal information that is linked or linkable to a specified individual.

Privacy Act Statements. When an individual is requested to furnish personal information about himself or
herself for inclusion in a system of records, providing a Privacy Act statement is required to enable the
individual to make an informed decision whether to provide the information requested.

Privacy Advisory. A notification informing an individual as to why information is being solicited and how such
information will be used. If PII is solicited by a DoD Web site (e.g., collected as part of an email feedback/
comments feature on a Web site) and the information is not maintained in a Privacy Act system of records, the
solicitation of such information triggers the requirement for a privacy advisory (PA).

System of Records Notice (SORN). Public notice of the existence and character of a group of records under
the control of any agency from which information is retrieved by the name of the individual or by some
identifying number, symbol, or other identifying particular assigned to the individual. The Privacy Act of 1974
requires this notice to be published in the Federal Register upon establishment or substantive revision of the
system, and establishes what information about the system must be included.

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