1625-0087 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-16700

Form Title:

North American Ice Service (NAIS) Customer Survey

Component:

U.S. Coast Guard (USCG) Office:

International Ice Patrol

IF COVERED BY THE PAPERWORK REDUCTION ACT:
North American Ice Service (NAIS) Customer Survey
Collection Title:
OMB Control
Number:
Collection status:

Name:
Office:
Phone:

Name:
Office:
Phone:

1625-0087
Extension

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

December 31, 2016
N/A

PROJECT OR PROGRAM MANAGER
LCDR Caroline Bell
International Ice Patrol
Ice Information Branch Chief
Title:
860-271-2643
[email protected]
Email:
COMPONENT INFORMATION COLLECTION/FORMS CONTACT
Anthony Smith
CG-612
PRA Coordinator
Title:
202-475-3532
[email protected]
Email:

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

SPECIFIC IC/Forms PTA QUESTIONS
1. Purpose of the Information Collection or Form
As outlined in Safety of Life at Sea (SOLAS) Chapter V regulation 6 and 46 USC 80301-2 the
U.S. Coast Guard is directed to maintain an ice patrol in the North Atlantic Ocean to study and
observe ice and current conditions. Ice dangers in the region shall be broadcast by available
means to trans-Atlantic and other passing vessels.
The Coast Guard International Ice Patrol, as directed by the Commandant of the Coast Guard
monitors the extent of the iceberg danger near the Grand Banks of Newfoundland and
provides iceberg warnings to the maritime community by broadcasting the southeastern,
southern, and southwestern limits of all known ice in two message bulletins and one radiofacsimile chart each day.
Executive Order 12862 directs the United States Coast Guard (USCG) to conduct surveys
(both qualitative and quantitative) to determine the kind and quality of services our customers
want and expect, as well as their satisfaction with USCG’s existing services. This survey will
be limited to data collections that solicit strictly voluntary opinions and will not collect
information that is required or regulated.

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.)

☐ 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.

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

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.
N/A

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:
e. What information will DHS collect on the form?
Vessel Name, Call sign, Home port.
f. Does this form collect Social Security number (SSN) or other element that is
stand-alone Sensitive Personally Identifiable Information (SPII)? No.
☐ Social Security number
☐ Alien Number (A-Number)
☐ Tax Identification Number
☐ Visa Number
☐ Passport Number
☐ Bank Account, Credit Card, or
other financial account number
☐ Other. Please list:

☐ 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

g. List the specific authority to collect SSN or these other SPII elements.
N/A
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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.
N/A
i. Are individuals
Yes, records subject fills out and submit the form.
provided notice
☐ No.
at the time of
collection by
DHS (Does the
records subject
have notice of
the collection or
is form filled out
by third party)?
3. How will DHS store the IC/form responses?
a. How will DHS store
☐ Paper. Please describe.
the original,
☐ Electronic. Please describe the IT system that will
completed IC/forms?
store the data from the form.

b. If electronic, how
does DHS input the
responses into the IT
system?

Privacy Threshold Analysis – IC/Form

Click here to enter text.
Scanned forms (completed forms are scanned into
an electronic repository). Please describe the
electronic repository.
The CG-16700 forms are scanned and kept on
the USCG network.
☐ Manually (data elements manually entered). Please
describe.
Click here to enter text.
☐ Automatically. Please describe.
Click here to enter text.
N/A

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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.
Click here to enter text.
By a non-personal identifier.
All Surveys are kept in an electronic folder on a Coast Guard
Workstation. Information is retrieved by opening each
survey individually.
Records are kept permanently according to the Information
and Life Cycle Management Manual (COMDTINST
M5212.12A).

d. What is the records
retention
schedule(s)? Include
the records schedule
number.
Data Collection Ice Operations records are kept permanently.
e. How do you ensure
They are transferred to NARA five years after the conclusion
that records are
disposed of or deleted of the project or the publication of the final record. (Ch. 1 to
CONDTINST M5212.12A).
in accordance with
the retention
schedule?
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.
Yes, information is shared external to DHS with other federal agencies, state/local
partners, international partners, or non-governmental entities. Please describe.
The survey is forwarded to the Canadian Ice Service (CIS).
☐ 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:

Robert Herrick

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

November 3, 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.)

November 16, 2017
☐ Yes. Please include it with this PTA
submission.
No. Please describe why not.
N/A. USCG Privacy will work with program
to remove privacy notice from existing form.

Component Privacy Office Recommendation:
North American Ice Service (NAIS) Customer Survey is not a privacy sensitive 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:

Riley Dean

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

1153729
November 16, 2017
November 16, 2020

DESIGNATION
Privacy Sensitive IC or
Form:

No If “no” PTA adjudication is complete.

Determination:

X 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.

Date IC/Form Approved Click here to enter a date.
by PRIV:
IC/Form PCTS Number: Click here to enter text.
Privacy Act
Choose an item.
Statement:
Privacy Notice already on form describing to survey participants how
submitted information will be used. This Notice can stay on the form,
but it can be amended to better describe that no personal information is
used through this survey, answers are not tied back to individuals, and
responses are voluntary.
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

PTA:

Choose an item.
Click here to enter text.
PIA:
Choose an item.
If covered by existing PIA, please list: Click here to enter text.
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.
USCG is submitting this PTA to discuss the North American Ice Service (NAIS)
Customer Survey, which is associated with OMB Control Number 1625-0087. USCG
maintains an ice patrol in the North Atlantic Ocean to study and observe ice and
current conditions. Ice dangers in the region are then broadcast by available means
to trans-Atlantic and other passing vessels. USCG conducts this survey to determine
the kind and quality of services trans-Atlantic and other passing vessels want and
expect, as well as their satisfaction with USCG’s existing services. This survey is
limited to data collections that solicit strictly voluntary opinions and will not collect
information that is required or regulated. No PII is collected by the survey.
The DHS Privacy Office finds that this survey is non-privacy sensitive.
While a Privacy Notice is already on form, it can be amended by labeling it a "Privacy
Notice" instead of "Privacy Act Notice," and can be edited to describe to better
describe that no personal information is used through this survey, answers are not
tied back to individuals, and responses are voluntary.

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Version number: 04-2016