1625-0040 Pta

Privacy Office
U.S. Department of Homeland Security
Washington, DC 20528
202-343-1717, [email protected]
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
[email protected]
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, [email protected]
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-719K/E

Form Title:
Component:

Application for Merchant Mariner Medical Certificate, Short Form
U.S. Coast Guard (USCG)
CG-MMC
Office:

IF COVERED BY THE PAPERWORK REDUCTION ACT:
Collection Title:

OMB Control
Number:
Collection status:

Application for Merchant Mariner Credential (MMC), Application for Merchant
Mariner Medical Certificate, Application for Merchant Mariner Medical Certificate
for Entry Level Ratings, Small Vessel Sea Service Form, DOT/USCG Periodic Drug
Testing Form, Disclosure Statement for Narcotics, DWI/DUI, and/or Other
Convictions, Merchant Mariner Medical Certificate, Recognition of Foreign
Certificate
1625-0040
January 31, 2016
OMB Expiration

Date:
Date of last PTA (if
applicable):

Revision

N/A

PROJECT OR PROGRAM MANAGER
Name:
Office:
Phone:

Michael Toth
NMC-4 Records Management
304-433-3729

Title:
Email:

Branch Chief
[email protected]

COMPONENT INFORMATION COLLECTION/FORMS CONTACT
Name:
Office:
Phone:

Anthony Smith

Title:
Email:

CG-612
202-475-3532

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PRA Coordinator
[email protected]
Version number: 04-2016

Privacy Office
U.S. Department of Homeland Security
Washington, DC 20528
202-343-1717, [email protected]
www.dhs.gov/privacy

SPECIFIC IC/Forms PTA QUESTIONS
1. Purpose of the Information Collection or Form
The Merchant Mariner Medical Certificate, Sort Form serves as proof that a mariner meets the required
medical and physical standards to serve in the capacities specified by the domestic and international
endorsements for which they apply.
The Application for Merchant Mariner Medical Certificate, Short Form contains the following
information: signature of applicant and supplementary material required to show that the mariner meets
the mandatory requirements for the credential or medical certificate sought; proof of applicant passing
all applicable vision, hearing, medical, and/or physical exams; negative chemical test for dangerous
drugs; discharges or other documentary evidence of sea service indicating the name, tonnage,
propulsion mode and power of the vessels, dates of service, capacity in which the applicant served, and
on what waters; and disclosure documentation for narcotics, DWI/DUI, and/or other convictions.
Title 46, Code of Federal Regulations (CFR), parts 10, 11, 12, 13, and 16, and International
Convention on Standards of Training, Certification and Watchkeeping for Seafarers, 1978, as amended
(STCW Convention) and the STCW Code, including the STCW Final Rule (Docket No. USCG-200417914) published on December 24, 2013.

2. Describe the IC/Form
a. Does this form collect any
Personally Identifiable
Information” (PII1)?
b. From which type(s) of
individuals does this form
collect information?
(Check all that apply.)

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

X Yes
☐ No
X Members of the public
X U.S. citizens or lawful permanent
residents
X Non-U.S. Persons.
☐ DHS Employees
☐ DHS Contractors
☐ Other federal employees or contractors.
X The record subject of the form (e.g., the
individual applicant).

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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Version number: 04-2016

Privacy Office
U.S. Department of Homeland Security
Washington, DC 20528
202-343-1717, [email protected]
www.dhs.gov/privacy

☐ 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 or contractor.
X Other individual/entity/organization that is
NOT the record subject. Please describe.
Medical Examiner

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

X Paper.
X Electronic. (ex: fillable PDF)
☐ Online web form. (available and submitted via
the internet)
Provide link:

e. What information will DHS collect on the form?
Record Subject: Full name, mariner reference number (MRN), gender, mailing address, email address,
date of birth, phone number, seamen’s medical information, status, and disposition, signature of
applicant.
Medical Examiner: Full name, medical license number, phone number, office address.

f. Does this form collect Social Security number (SSN) or other element that is
stand-alone Sensitive Personally Identifiable Information (SPII)? Check all that
apply.
☐ Social Security number
☐ Alien Number (A-Number)
☐ Tax Identification Number
☐ Visa Number
☐ Passport Number
☐ Bank Account, Credit Card, or other
financial account number
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☐ 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
Version number: 04-2016

Privacy Office
U.S. Department of Homeland Security
Washington, DC 20528
202-343-1717, [email protected]
www.dhs.gov/privacy

X Other. Please list: Medical information
g. List the specific authority to collect SSN or these other SPII elements.
5 U.S.C. 301; 14 U.S.C. 632; 46 U.S.C. 2103, 7302, 7305, 7314, 7316, 7319, 7502, 7701, 8701; 46
CFR 12.02-25; 49 CFR 1.45, 1.46.

h. How will this information be used? What is the purpose of the collection?
Describe why this collection of SPII is the minimum amount of information
necessary to accomplish the purpose of the program.
The purpose of this system is to administer the Commercial Vessel Safety Program to determine
domestic and international qualifications for the issuance of seaman credentials with domestic and
international endorsements, licenses, documents, and staff officer certifications. This includes
establishing eligibility for a merchant mariner’s credential, duplicate credential, or additional
endorsements issued by the USCG and establishing and maintaining continuous records of the person’s
documentation transactions.

i.

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)?

X Yes. Please describe how notice is provided.
Privacy Act Statement on form.

☐ No.

3. How will DHS store the IC/form responses?
a. How will DHS store
X Paper. Please describe.
the original,
Paper files are stored at secure, controlled access sites
managed by either Coast Guard personnel or contract
completed IC/forms?

personnel with oversight from Coast Guard personnel.
Inactive records are stored by NARA at that agency's
Federal Records Centers facilities.

X Electronic. Please describe the IT system that will
store the data from the form.
Electronic records are stored in the Merchant Mariner
Licensing and Documentation System on a secure server at
the Coast Guard Operation Systems Center.

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Version number: 04-2016

Privacy Office
U.S. Department of Homeland Security
Washington, DC 20528
202-343-1717, [email protected]
www.dhs.gov/privacy

☐ Scanned forms (completed forms are scanned into
an electronic repository). Please describe the
electronic repository.
Click here to enter text.
b. If electronic, how
does DHS input the
responses into the IT
system?

X Manually (data elements manually entered). Please
describe.
Data is entered by either Coast Guard personnel or
contract personnel with oversight from Coast Guard
personnel.

☐ 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?

X By a unique identifier.2 Please describe. If
information is retrieved by personal identifier, please
submit a Privacy Act Statement with this PTA.
Information is retrieved by any combination of the various
categories of records listed in previous sections (e.g.
name, address, Social Security number, and Merchant
Mariner Licensing and Documentation System assigned
system number).

☐ By a non-personal identifier. Please describe.
Click here to enter text.
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
in accordance with
the retention
schedule?

SSIC 16720
Destroy 60 years after last discharge or evidence of death is
reviewed, whichever is sooner.

Quarterly the Headquarters Support Command (HSC) Records
Coordinator will contact appropriate program managers
regarding any of their scheduled records due for destruction. It is
essential that owners of records have an opportunity to indicate if
subject records might be required for impending litigation or
some other need. Even if records have met their specified
retention periods, they cannot be destroyed without the

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.
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Version number: 04-2016

Privacy Office
U.S. Department of Homeland Security
Washington, DC 20528
202-343-1717, [email protected]
www.dhs.gov/privacy

concurrence of the program manager having legal custody of the
records.

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.
X Yes, information is shared external to DHS with other federal agencies, state/local
partners, international partners, or non-governmental entities. Please describe.
Information may be released to a third party if specific guidance is given to the National Maritime
Center (NMC), by the applicant, regarding what issues may be discussed and with whom. The
applicant must complete a Third Party Authorization for each entity or individual named.

☐ 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, [email protected]
www.dhs.gov/privacy

PRIVACY THRESHOLD REVIEW
(TO BE COMPLETED BY COMPONENT PRIVACY OFFICE)
Component Privacy Office Reviewer:

Robert Herrick

Date submitted to component Privacy
Office:
Date submitted to DHS Privacy Office:

August 22, 2017

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.)

Click here to enter a date.
X Yes. Please include it with this PTA
submission.
USCG Privacy will work with the program to update
the PAS to a Privacy Notice.

☐ No. Please describe why not.
Click here to enter text.

Component Privacy Office Recommendation:
The Merchant Mariner Medical Certificate serves as proof that a mariner meets the required medical and
physical standards to serve in the capacities specified by the domestic and international endorsements for
which they apply.
The Merchant Mariner Medical Certificate collects name, mariner reference number (MRN), gender,
mailing address, email address, date of birth, phone number, seamen’s medical information, status, and
disposition, signature of applicant. The form also collects name, medical license number, phone number
and office address of the medical examiner.
This collection is covered by DHS/USCG/PIA-015 Merchant Mariner Licensing and Documentation
System and DHS/USCG-030 Merchant Seamen’s Records.

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Version number: 04-2016

Privacy Office
U.S. Department of Homeland Security
Washington, DC 20528
202-343-1717, [email protected]
www.dhs.gov/privacy

PRIVACY THRESHOLD ADJUDICATION
(TO BE COMPLETED BY THE DHS PRIVACY OFFICE)
DHS Privacy Office Reviewer:

Riley Dean

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

1149347
August 31, 2017
August 31, 2020

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.
X Privacy Act Statement required.
X Privacy Impact Assessment (PIA) required.
X System of Records Notice (SORN) required.
☐ Specialized training required.
☐ Other. Click here to enter text.

DHS IC/Forms Review:

Choose an item.

Date IC/Form Approved Click here to enter a date.
by PRIV:
IC/Form PCTS Number: Click here to enter text.
Privacy Act
Privacy Notice required
USCG Privacy should work with the program to update the Privacy Notice as
Statement:
required.

PTA:
PIA:

Choose an item.
Click here to enter text.
System covered by existing PIA

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, [email protected]
www.dhs.gov/privacy

If covered by existing PIA, please list: DHS/USCG/PIA-015 Merchant
Mariner Licensing and Documentation System
If a PIA update is required, please list: Click here to enter text.
SORN:
System covered by existing SORN
If covered by existing SORN, please list: DHS/USCG-030 Merchant
Seamen's Records, June 25, 2009 74 FR 30308
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 submitting this PTA to discuss the Application for Merchant Mariner Medical
Certificate, Short Form (CG-719K/E), which is associated with OMB control number
1625-0040. The certificate serves as proof that a mariner meets the required
medical and physical standards to serve in the capacities specified by the domestic
and international endorsements for which they apply.
The application requires the following information be submitted for the record
subject: name, mariner reference number (MRN), gender, mailing address, email
address, date of birth, phone number, seamen’s medical information, status, and
disposition, signature of applicant. The following information is collected form a
medical examiner: name, license number, phone number, office address. These
records are stored in the Merchant Mariner Licensing and Documentation System on
a secure server at the Coast Guard Operation Systems Center.
The DHS Privacy Office agrees that this form is privacy-sensitive, and PIA and SORN
coverage are required.
PIA coverage is provided by DHS/USCG/PIA-015 Merchant Mariner Licensing and
Documentation System, which outlines the risks of collecting PII in order to manage
the issuance of credentials to Merchant Mariners and process merchant mariner
applications; the records include the credential, background check, and medical
status. SORN coverage is provided by DHS/USCG-030 Merchant Seamen’s Records,
which allows for the collection of PII to establish eligibility of a merchant mariner's
document, duplicate documents, or additional endorsements issued by USCG.
USCG Privacy should work with the program to update the Privacy Notice as
required.

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Version number: 04-2016