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.

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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:

TSA Form 1604

Form Title:
Component:

Critical Facility Security Review (CFSR)
Transportation Security Office:
Administration (TSA)

Office of Security
Policy & Industry
Engagement (OSPIE) –
Surface Division
IF COVERED BY THE PAPERWORK REDUCTION ACT:
Collection Title:
Critical Facility Information of the Top 100 Most Critical Pipeline
OMB Control
Number:
Collection status:

Name:
Office:
Phone:
Name:
Office:
Phone:

1652-0050

OMB Expiration
April 30, 2018
Date:
Extension
Date of last PTA (if
N/A
applicable):
PROJECT OR PROGRAM MANAGER
Steven Froehlich
OSPIE Surface Division
Title:
Transportation Security
Specialist
[email protected]
571-227-1240
Email:
COMPONENT INFORMATION COLLECTION/FORMS CONTACT
Glenn Stoll
Information Management
Title:
IMPS Director, Forms
Program Section (IMPS)
Management Officer
571-227-5175
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

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.
TSA visits critical pipeline facilities to collect site-specific information from
pipeline operators on facility security policies, procedures, and physical security
measures. TSA analyzes the information collected on the CFSR form during the
onsite facility reviews, as well as the information collected from follow-ups with
facility operators on the status of recommendations made during the reviews to
determine: strengths and weaknesses at the nation's critical pipeline facilities;
areas to target for risk reduction strategies; pipeline industry implementation of
the TSA “Pipeline Security Guidelines;” and operator implementation of
recommendations made during TSA critical facility visits.
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.
Section 1557 of the 9/11 Act ((P.L. 110-53, 121 Stat. 266, 475 (August 3, 2007)
codified at 6 USC 1207(b)) requires that TSA develop and implement a plan for
reviewing pipeline security plans and inspecting critical pipeline systems.

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

☒ Yes
☐ No
☒ Members of the public
☒ U.S. citizens or lawful permanent
residents

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

collect information?
(Check all that apply.)

☒ 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:

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.
Pipeline operator’s name, official title and business contact information: office and
cellular phone numbers, email 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.
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Privacy Office
U.S. Department of Homeland Security
Washington, DC 20528
202-343-1717, [email protected]
www.dhs.gov/privacy

☐ 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
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)?

☒ Yes. Please describe how notice is provided.
Operators receive a copy of the form in advance of
inspection to review and complete if they choose.
☐ No.

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.
The data and electronic copies of the final forms
are maintained in an Access database on a
government-provided stand-alone computer
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Privacy Office
U.S. Department of Homeland Security
Washington, DC 20528
202-343-1717, [email protected]
www.dhs.gov/privacy

accessible only to personnel contracted by TSA to
perform the inspections. All pipeline facility
information on the form and in the database are
considered Sensitive Security Information (SSI)
and protected accordingly.
☐ 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?

☒ Manually (data elements manually entered). Please
describe.
After inspection, the contractor enters the form
information into the database.
☐ 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.
Information is retrieved by company and/or
facility names.
In accordance with NARA Authority N1-560-11-2,
Item 1, and TSA Records Disposition Schedule 1600.4,
Surface Mode Assessment records are cut off at the
end of the fiscal year, then destroyed/deleted seven
years after cut-off.
Records are reviewed at the end of each FY to identify
any no longer needed for analysis or business
purpose that have been maintained for seven years
from the cut-off date. These records are then
destroyed or deleted.

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

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.
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:

Jennifer L. Schmidt

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

November 29, 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.
☐ Yes. Please include it with this PTA
submission.
☒ No. Please describe why not.
Not Privacy Act protected records.

Component Privacy Office Recommendation:
Please include recommendation below, including what existing privacy compliance
documentation is available or new privacy compliance documentation is needed.
TSA Privacy recommends approval of this PTA. The collection of business PII from
members of the public has PIA coverage under DHS/ALL/PIA-006, DHS General
Contacts Lists. SORN coverage is not required because the records are not protected
by the Privacy Act or retrieved by a unique personal identifier.

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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:

Sean McGuinness

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

1154464
December 1, 2017
December 1, 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 not received this ICR/Form.

Date IC/Form Approved Click here to enter a date.
by PRIV:
IC/Form PCTS Number: Click here to enter text.
Privacy Act
e(3) statement not required.
Statement:
Click here to enter text.
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 General
Contact Lists
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.
DHS Privacy Office finds that the Critical Facility Security Review (CFSR) TSA Form
1604 is privacy sensitive as it collects PII from members of the public (including U.S.
citizens or lawful permanent residents and Non-U.S. Persons.
TSA uses Form 1604 to collect site-specific information from pipeline operators on
facility security policies, procedures, and physical security measures during a TSA
visit to a critical pipeline facility. This information is collected to determine
strengths and weaknesses at the nation's critical pipeline facilities; areas to target
for risk reduction strategies; pipeline industry implementation of the TSA “Pipeline
Security Guidelines;” and operator implementation of recommendations made
during TSA critical facility visits. PII submitted on this form includes the pipeline
operator’s name and business contact information (office and cellular phone
numbers and email address).
PRIV agrees with TSA Privacy that PIA coverage is provided under DHS/ALL/PIA-006
General Contact Lists. DHS/ALL/PIA-006 outlines how DHS collects contact
information in order to distribute information and perform various other
administrative tasks.
A Privacy Act Statement is not required as information on this form is not retrieved
by personal identifier. Information is retrieved by company and/or facility names.

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