1625-0086 Uscg 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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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-4509

Form Title:

APPLICATION FOR REGISTRATION AS UNITED STATES
REGISTERED PILOT

Component:

U.S. Coast Guard (USCG) Office:

CG-WWM

IF COVERED BY THE PAPERWORK REDUCTION ACT:
Great Lakes Pilotage
Collection Title:
OMB Control
Number:
Collection status:

Name:
Office:
Phone:

Name:
Office:

1625-0086
Extension

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

December 31, 2016
N/A

PROJECT OR PROGRAM MANAGER
Vincent F. Berg
CG-WWM-2
Transportation Specialist
Title:
202-372-1535
[email protected]
Email:

COMPONENT INFORMATION COLLECTION/FORMS CONTACT
Vincent F. Berg
CG-WWM-2
Transportation Specialist
Title:

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

Phone:

202-372-1535
Email:
[email protected]
SPECIFIC IC/Forms PTA QUESTIONS

1. Purpose of the Information Collection or Form
The Coast Guard will use this information to review mariner credentials and qualifications
against eligibility requirements for providing registered pilotage on the Great Lakes.
Coast Guard authorities to collect this information are 46 U.S.C. §9303 and 46 CFR §401.210.

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?

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.

☐ 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.

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

e. What information will DHS collect on the form?
Name, mailing address, email, phone number, document number, and reference number.
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: Document number,

Reference Number

g. List the specific authority to collect SSN or these other SPII elements.
46 U.S.C. §9303 and 46 CFR §401.210.

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

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 the collection form CG-4509 is to carry out operational and rate making
oversight of pilotage activities on the Great Lakes.

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 is posted on the bottom of CGForm 4509.

3. How will DHS store the IC/form responses?
a. How will DHS store
☐ Paper. Please describe.
the original,
The forms will be stored in a locked file cabinet in a
completed IC/forms?
level 5 secure building.
☐ 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 CG also keeps the application in CG-WWM-2
shared drive with the pilots files.
b. If electronic, how
does DHS input the
responses into the IT
system?

Privacy Threshold Analysis – IC/Form

☐ Manually (data elements manually entered). Please
describe.
The CG scans the hand written application into CGWWM-2 shared folder.
☐ Automatically. Please describe.
Click here to enter text.
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Privacy Office
U.S. Department of Homeland Security
Washington, DC 20528
202-343-1717, [email protected]
www.dhs.gov/privacy

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.
By the pilots name. The Privacy Act Statement is on
the bottom of Form CG-4509.
☐ By a non-personal identifier. Please describe.
Click here to enter text.
Destroy 6 years after the individual license expires, upon
death of the individual or when the individual turns 70 years
old, whichever is sooner; NARA retention schedule number
N1-026-05-2.

d. What is the records
retention
schedule(s)? Include
the records schedule
number.
Records are disposed of in accordance Great Lakes
e. How do you ensure
Registered Pilot and Applicant Pilot Eligibility Records
that records are
retention schedule.
disposed of or deleted
in accordance with
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.
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.
The CG-4509 Application for Registered Pilot is shared with the three pilot district
associations, Saint Lawrence Seaway Pilots' Association, Lakes Pilots Association, &
Western Great Lakes Pilots Association, the Coast Guard regulates. After the CG
determines the individual meets all the requirements in accordance with the regulations,
the pilot associations hire the individuals based on the application.
☐ No. Information on this form is not shared outside of the collecting office.
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

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.)

Kenlinishia Tyler
October 6, 2016

November 1, 2016

☐ Yes. Please include it with this PTA
submission.
x No. Please describe why not.
The form has been in previous existence. A
Privacy Act Statement can be found at the
bottom of the form.

Component Privacy Office Recommendation:
Please include recommendation below, including what existing privacy compliance
documentation is available or new privacy compliance documentation is needed.
CG-Form 4509 (i.e. Application for Registration as United States Registered Pilot) is a privacy
sensitive form used to document credentials/qualifications for an original or renewal registered
pilot license.
DHS/USCG/PIA-015 and DHS/USCG-006 provides coverage for this collection.

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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:

Michael Capparra

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

1134659
November 8, 2016
November 8, 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: Choose an item.

Click here to enter a date.
Date IC/Form
Approved by PRIV:
Click here to enter text.
IC/Form PCTS
Number:
Privacy Act
Choose an item.
Statement:
The current PA statement included on the form is sufficient.
PTA:
Choose an item.
The PTA currently on file with PRIV is sufficient.
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Privacy Office
U.S. Department of Homeland Security
Washington, DC 20528
202-343-1717, [email protected]
www.dhs.gov/privacy

PIA:

System covered by existing PIA
If covered by existing PIA, please list: DHS/USCG/PIA-015 Merchant
Mariner Licensing and Documentation System 2011
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-006 Great Lakes
Registered Pilot and Applicant Pilot Eligibility, December 16, 2014, 79
FR 74744
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.
The DHS Privacy Office finds that the Application for Registration as United States Registered
Pilot Form represents a privacy sensitive collection of information. The Form collects contact and
license information from individuals in order to compare their mariner credentials and
qualifications against the eligibility requirements for providing registered pilotage on the Great
Lakes. A Privacy Act Statement outlining the authorities, reason for collection, and uses of
information is provided on the form. PIA coverage is provided by DHS/USCG/PIA-015 Merchant
Mariner Licensing and Documentation System, which assess the use of PII from members of the
public as part of its effort to manage the issuance of credentials to Merchant Mariners and
process merchant mariner applications; produce merchant mariner credentials; and track
merchant mariner credentials issued by the Coast Guard. SORN coverage is provided by
DHS/USCG-006 Great Lakes Registered Pilot and Applicant Pilot Eligibility, which outlines the
Coast Guard’s collection of information in order to assist USCG in meeting its statutory obligation
to establish, regulate, and oversee the operations of a pilotage system on the Great Lakes, to
maintain records of individuals who are registered as Great Lakes pilots to perform pilotage
duties aboard foreign trade vessels on the Great Lakes, and to maintain applications of mariners
seeking registration as a Great Lakes pilot.

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