PTA, NPPD - Gratuitous Services Agreement Volunteer Participant Release ...

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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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:

TBD

Form Title:

Gratuitous Services Agreement/Volunteer Participant Release of Liability
Agreement

Component:

National Protection and
Programs Directorate
(NPPD)

Office:

Office of Infrastructure
Protection

IF COVERED BY THE PAPERWORK REDUCTION ACT:
Collection Title:
Gratuitous Services Agreement and Volunteer Release and Hold Harmless
OMB Control
Number:
Collection status:

Name:
Office:

Phone:

TBD
New Collection

OMB Expiration
Date:
Date of last PTA (if
applicable):

TBD
N/A

PROJECT OR PROGRAM MANAGER
Michael A. Dailey
NPPD/IP/PSCD’s Office for Title:
Chief
Bombing Prevention
Training and Awareness
Section
703-235-9387
Email:
[email protected]

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

Name:
Office:

Phone:

COMPONENT INFORMATION COLLECTION/FORMS CONTACT
Evette Maynard-Noel
NPPD/OUS
Title:
Chief, Information
Management, IT
Accessibility, and
Knowledge Management
571-294-3360
Email:
[email protected]
SPECIFIC IC/Forms PTA QUESTIONS

1. Purpose of the Information Collection or Form
a. Describe the purpose of the information collection or form. Please provide a
general description of the project and its purpose, including how it supports the DHS
mission, in a way a non-technical person could understand (you may use
information from the Supporting Statement).
If this is an updated PTA, please specifically describe what changes or upgrades are
triggering the update to this PTA.
The purpose of this collection is to absolve the Department of any risk or liability relating
to individuals’ volunteer participation in field training exercises. There are two separate
forms that are covered under this collection:
 Gratuitous Services Agreement
 Volunteer Participant Release of Liability Agreement
Individuals whom volunteer to assist in field training exercises are required to sign these
particular forms in order to a.) acknowledge that they are volunteering and will not be
compensated for their participation, and to b.) release the Department from any and all
liability for injury that may occur as a result of their participation.
b. List the DHS (or component) authorities to collect, store, and use this information.
If this information will be stored and used by a specific DHS component, list the
component-specific authorities.
Information will be collected, stored, and used in support of training provided per
Presidential Policy Directive (PPD-17) - Countering Improvised Explosive Devices
Implementation Plan.

2. Describe the IC/Form

Privacy Threshold Analysis – IC/Form

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

a. Does this form collect any
Personally Identifiable
Information” (PII1)?

☒ Yes
☐ No

b. From which type(s) of
individuals does this form
collect information?
(Check all that apply.)

☒ Members of the public
☒ U.S. citizens or lawful permanent
residents
☒ Non-U.S. Persons.
☐ DHS Employees
☐ DHS Contractors
☒ Other federal employees or contractors.

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

☒ 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 or contractor.
☐ Other individual/entity/organization that is
NOT the record subject. Please describe.
Click here to enter text.

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

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

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

e. What information will DHS collect on the form? List all PII data elements on the
form. If the form will collect information from more than one type of individual,
please break down list of data elements collected by type of individual.
The forms collect the name (first and last) and the signature of the individual
volunteering to assist in field training exercises.
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
☐ DHS Electronic Data Interchange
Personal Identifier (EDIPI)
☐ Alien Number (A-Number)
☐ Social Media Handle/ID
☐ Tax Identification Number
☐ Known Traveler Number
☐ Visa Number
☐ Trusted Traveler Number (Global
☐ Passport Number
Entry, Pre-Check, etc.)
☐ Bank Account, Credit Card, or other
☐ Driver’s License Number
financial account number
☐ Biometrics
☐ Other. Please list:
g. List the specific authority to collect SSN or these other SPII elements.
N/A

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.
N/A

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)?

Privacy Threshold Analysis – IC/Form

☒ Yes. Please describe how notice is provided.
The forms include a privacy notice and are filled
out and signed by the individual volunteering to
assist in field training exercises.
☐ No.

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

3. How will DHS store the IC/form responses?
a. How will DHS store
☐ Paper. Please describe.
the original,
Click here to enter text.
completed IC/forms?
☐ 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.
The scanned forms will be saved in a secure folder
on the Shared Drive (dhsnet.ds1.dhs/I&A_Shares).
b. If electronic, how
does DHS input the
responses into the IT
system?

☐ Manually (data elements manually entered). Please
describe.
Click here to enter text.
☐ 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?

☐ 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.
The forms are stored and retrieved by the training
course name/number that the individual
supported.
These forms will be filed as Training Records
under PSCD’s File Plan 403-258-003c. The
Disposition will be under General Record Schedule
(GRS) 01, item 29. OBP will use the Records and
Information Management Directive 141-01
(8/2014) as standard guidance to follow.

d. What is the records
retention
schedule(s)? Include
the records schedule
number.

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

e. How do you ensure
that records are
disposed of or deleted
in accordance with
the retention
schedule?

These records are categorized as “Temporary” and in
accordance with the retention schedule will be
destroyed 5 years after completion of the
training. Once the forms start to be collected, the OBP
Countering Improvised Explosive Device (C-IED)
Training and Awareness Section (CTAS) will perform
an annual review of the record dates and delete those
at the end of the 5 year retention schedule.
f. Is any of this information shared outside of the original program/office? If yes,
describe where (other offices or DHS components or external entities) and why.
What are the authorities of the receiving party?
☐ 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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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:

Brad Bartel/Dianna Carr

Date submitted to component Privacy
Office:
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.)

July 22, 2016
August 4, 2016
☐ Yes. Please include it with this PTA
submission.
☒ No. Please describe why not.
Records are not filed or retrieved by
personal identifier and are not subject to
the Privacy Act.

Component Privacy Office Recommendation:
Please include recommendation below, including what existing privacy compliance
documentation is available or new privacy compliance documentation is needed.
The NPPD Office of Privacy has determined this collection to be of low sensitivity due
to the minimal amount of PII collected (e.g., Name, Signature). The NPPD Office of
Privacy recommends that this PTA is sufficient at this time and that no additional
privacy compliance documentation is needed.

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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

1129431
September 7, 2016
September 7, 2019

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

DHS IC/Forms Review:

DHS PRIV has commented on this ICR/Form.

Date IC/Form Approved Click here to enter a date.
by PRIV:
IC/Form PCTS Number: 1124683
Privacy Act
e(3) statement not required.
Statement:
Records are not filed or retrieved by personal identifier and are not
subject to the Privacy Act.
PTA:
No system PTA required.
Click here to enter text.
PIA:
System covered by existing PIA
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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/ALL/PIA-006 DHS General
Contacts List
If a PIA update is required, please list: Click here to enter text.
SORN:
Choose an item.
If covered by existing SORN, please list: Click here to enter text.
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.
NPPD is submitting this Forms-PTA to discuss the collection of PII associated with a
new collection that requires the issuance of a new OMB number. The purpose of this
collection is to absolve DHS of any risk or liability relating to individuals’ volunteer
participation in training exercises. There are two separate forms that are covered
under this collection: the Gratuitous Services Agreement and the Volunteer
Participant Release of Liability Agreement. Individuals who volunteer to assist in
field training exercises are required to sign these particular forms. The only PII that
is collected is name and signature.
The collection of this information is covered by DHS/ALL/PIA-006 DHS General
Contacts List, which outlines the privacy risks associated with DHS operations and
projects that collect a minimal amount of PII in order to perform various other
administrative tasks. No SORN or Privacy Act Statement are required.

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