Privacy Threshold Analysis

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.
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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:
Form Title:
Component:

Form I-102

Application for Replacement/Initial Nonimmigrant ArrivalDeparture Document
U.S. Citizenship and
Office:
Service Center
Immigration Services
Operations (SCOP)
(USCIS)

IF COVERED BY THE PAPERWORK REDUCTION ACT:
Collection Title:
Form I-102, Application for Replacement/Initial Nonimmigrant
Arrival-Departure Document
OMB Control
OMB No. 1615-0079
OMB Expiration
October 31, 2017
Number:
Date:
Collection status: Extension
Date of last PTA (if July 11, 2013
applicable):
Name:
Office:
Phone:
Name:

PROJECT OR PROGRAM MANAGER
Rakhee Patel
SAFE
Title:
Adjudications Officer
[email protected]
202-272-8472
Email:

COMPONENT INFORMATION COLLECTION/FORMS CONTACT
Kerstin Jager

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

Office:

Phone:

Regulatory Coordination
Title:
Project Manager
Division
[email protected]
(202) 213-4211
Email:
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.
Form Extension
Form I-102, Application for Replacement/Initial Nonimmigrant Arrival Departure
Document will expire on October 31, 2017. USCIS is submitting the Form I-102 PTA
because the form is expiring, and will be extended with minor updates to include updating
standard form language and USCIS online account number field.
The updated Form I-102 includes the USCIS Online Account Number field for collecting
this information if USCIS previously issued this number to the alien. USCIS uses the USCIS
Online Account Number to enhance customer service and the quality of our processes.
Form I-102 will be added to USCIS ELIS and available for e-filing at a later date.
Form I-102, Application for Replacement/Initial Nonimmigrant Arrival-Departure
Form I-102, Application for Replacement/Initial Nonimmigrant Arrival-Departure
Document is used to file to USCIS for the following circumstances :
1. To replace a lost or stolen Form I-94;
2. To replace a mutilated Form I-94; or

3. A Form I-94 was not issued when an alien entered the United States as nonimmigrant.

Relevant Information Technology
The Computer Linked Application Information System (CLAIMS 3) assists in processing
Form I-102. The information in CLAIMS 3 is used for the adjudication and/or granting or
denial of immigration benefits. CLAIMS 3 enables USCIS to efficiently process and
adjudicate cases by tracking each case through all aspects of the immigration and
citizenship process, from application submission to close-out. The physical form and

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

supplemental evidence is stored in the A-File and may be electronically scanned into
EDMS.
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.
The authority to collect information in this form is set forth in the Immigration and
Nationality Act, 8 U.S.C. §§ 1103, 1201, 1303, 1304, 1305, and in the implementing
regulations found in volume 8 of the Code of Federal Regulations (CFR).
2. Describe the IC/Form
a. Does this form collect any
Personally Identifiable
Information” (PII 1)?

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.)

☒ Yes
☐ No

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

☒ 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.

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

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

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

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

This form is not currently available for e-filing.
The electronic fillable PDF version can be found
here: https://www.uscis.gov/i-102
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.
Information collected about the principal applicant include:
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•

Full Name
U.S. Mailing Address
U.S. Physical Address
Date of Birth
Country of Birth
Country of Citizenship/Nationality
A-Number
USCIS Online Account Number
Social Security Number (if applicable)
Current Nonimmigrant status
Date Nonimmigrant Status Expires
Date of Last Entry into the United States
Place of Last Entry into the United States
I-94/I-94W/I-95 Arrival/Departure document number
Passport Number
Travel Document Number
Country of Issuance for Passport or Travel Document
Expiration Date for Passport or Travel Document
Reason for application

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

•
•
•
•
•
•
•

Processing information
Class of Admission at Last Entry into the United States
Place of Last Entry into the United States (City and State)
Signature
Daytime Phone Number
Mobile Telephone Number
Email Address date

Information collected about the interpreter includes:
•
•
•
•
•
•
•
•

Full name
Business or Organization Name
Mailing address
Day Telephone number
Email Address
Language fluency
Signature
Date of Signature

Information collected about the preparer includes: Daytime Telephone
Number
• Fax Number
• Email Address
• Accredited Representative
• Full Name
• Business or Organization Name
• Signature and Declaration
• Date of Signature
• Mailing 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
☐ 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
•

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

☒ Other. Please list: Travel Document
Number

☐ Biometrics

g. List the specific authority to collect SSN or these other SPII elements.
INA 264(f) (8 U.S.C. 1304(f)) provides the Secretary of Homeland Security with the
specific authority to collect SSNs of those applying for immigration benefits.

The authority to collect other SPII elements in this form is set forth in the Immigration
and Nationality Act, 8 U.S.C. §§ 1103, 1201, 1303, 1304, 1305, and in the implementing
regulations found in volume 8 of the Code of Federal Regulations (CFR).
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.
USCIS collects the SSN to facilitate and expedite the adjudication of the applicant’s
request for a Form I-102 replacement arrival departure record. The SSN information is
used to establish and corroborate the applicant’s identity.

The SSN information collected within the Form I-102 application is also used to assist
DHS in enforcing the immigration laws of the United States by providing timely and
accurate information about persons who are subject to those laws. USCIS personnel
conduct background security checks on applicants for the purpose of determining
whether the applicant has established eligibility for the benefit requested. Because the I102 is typically a non-interview, paper-based adjudication, the SSN is especially useful
and provides significant information to verify an applicant’s identity and his/her claim to
eligibility, providing a critical tool for more accurate and appropriate adjudication
determinations for USCIS and the applicant.
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.
Form I-102 instructions contain a USCIS Privacy Act
Statement
☐ 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,
Form I-102 is stored in an A-File
completed IC/forms?
☒ Electronic. Please describe the IT system that will

b. If electronic, how
does DHS input the
responses into the IT
system?
c. How would a user
search the
information
submitted on the
forms, i.e., how is the
information
retrieved?

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

store the data from the form.
CLAIMS 3
☒ Scanned forms (completed forms are scanned into
an electronic repository). Please describe the
electronic repository.
Electronic Database Management System

☒ Manually (data elements manually entered). Please
describe.
Information from forms typed into CLAIMS 3.☐
Automatically. Please describe.
N/A

☒ By a unique identifier. 2 Please describe. If
information is retrieved by personal identifier, please
submit a Privacy Act Statement with this PTA.
A-number, Receipt Number, Name and Date of
Birth
☐ By a non-personal identifier. Please describe.
Click here to enter text.
Form I-102: N1-85-90-04
A-File: N1-566-08-11
CLAIMS3: DAA-0566-2016-0009
Program office following the records retention schedule
for filing and destruction of records.

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

the 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.
☐ Yes, information is shared external to DHS with other federal agencies, state/local
partners, international partners, or non-governmental entities. Please describe.
N/A
☒ 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:

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.)

Nina Robinson
May 1, 2017
May 17, 2017
☒ Yes. Please include it with this PTA
submission.
☐ No. Please describe why not.

Component Privacy Office Recommendation:
Please include recommendation below, including what existing privacy compliance
documentation is available or new privacy compliance documentation is needed.
The USCIS Office of Privacy recommendation is to designate Form I-102 as privacy
sensitive with coverage under the following privacy compliance documentation :
PIA
•

•

DHS/USCIS/PIA-003(b) Integrated Digitization Document Management Program,
which covers the digitization and storage of forms in the Enterprise Document
Management System
DHS/USCIS/PIA-016 Computer Lined Application Information Management System
(CLAIMS 3) and Associated Systems, which covers the processing and adjudication
of Form I-102.

SORN
• DHS/USCIS-001 Alien File, Index, and National File Tracking System of Records
which covers the collection, use, and storage of the Form I-102 in the A-file
• DHS/USCIS-007 Benefits Information system, which covers the collection, use and
storage of data elements USCIS collects from the applicants, preparers, and
interpreters
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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:

Max Binstock

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

1143055
May 17, 2017
May 17, 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.
☒ 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 approved this ICR/Form.
Date IC/Form Approved May 17, 2017
by PRIV:
IC/Form PCTS Number: Click here to enter text.
Privacy Act
New e(3) statement is required.
Statement:
A new Privacy Notice is required
PTA:
New system PTA required.
PIA:
System covered by existing PIA
If covered by existing PIA, please list: DHS/USCIS/PIA-003(b)
Integrated Digitization Document Management Program;
DHS/USCIS/PIA-016(a) Computer Lined Application Information
Management System (CLAIMS 3) and Associated Systems

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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 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/USCIS/ICE/CBP-001 Alien
File, Index, and National File Tracking System of Records, November 21,
2013, 78 FR 69864; DHS/USCIS-007 Benefits Information System,
October 19, 2016, 81 FR 72069
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.

USCIS Privacy is submitting this PTA because the Form I-102 PTA is expiring, and
will be extended with minor updates to include updating standard form language
and USCIS online account number field. The updated Form I-102 includes the USCIS
Online Account Number field for collecting this information if USCIS previously
issued this number to the alien. USCIS uses the USCIS Online Account Number to
enhance customer service and the quality of our processes. Form I-102 will be added
to USCIS ELIS and available for e-filing at a later date.
PRIV finds that is a privacy sensitive system and a PIA is required because Form I102 collects PII from non US persons. PRIV agrees with USCIS Privacy
recommendation that the IDDMP PIA and CLAIMS 3 PIA provide coverage.
DHS/USCIS/PIA-003(b) covers the digitization and storage of forms in the Enterprise
Document Management System. DHS/USCIS/PIA-016(a) covers the processing and
adjudication of Form I-102.
PRIV finds that is a SORN is required because Form I-102 retrieves information by a
unique identifier. PRIV agrees with USCIS Privacy that the A-File SORN and BIS SORN
provides coverage. DHS/USCIS/ICE/CBP-001 covers the collection, use, and storage
of the Form I-102 in the A-File. DHS/USCIS-007 covers the collection, use and storage
of data elements USCIS collects from the applicants, preparers, and interpreters.
PRIV finds that a Privacy Notice is required to inform the individual about the
authority to collect the information requested, purposes for collecting it, routine
uses, and consequences of providing or declining to provide the information to
USCIS.
Please submit a new Form I-102 PTA prior to it being added to USCIS ELIS.

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