1625-0057 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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Version number: 04-2016

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:

CG-5256

Small Passenger Vessel Inspection sticker

Component:

U.S. Coast Guard (USCG)

Office:

CG-REG

IF COVERED BY THE PAPERWORK REDUCTION ACT:
Collection Title:
Small Passenger Vessels –- Title 46 CFR Subchapters K and T
OMB Control
Number:
Collection status:

Name:
Office:
Phone:

Name:
Office:
Phone:

1625-0057
Extension

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

July 31, 2017
N/A

PROJECT OR PROGRAM MANAGER
Mr. David Du Pont
CG-REG
Title:
Reg Dev Mgr
202-372-1497
Email:
[email protected]

COMPONENT INFORMATION COLLECTION/FORMS CONTACT
Mr. Arthur Requina
CG-612
Title:
Forms Manger
202-475-3651
Email:
[email protected]

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
The purpose of the form (sticker) is to certify that a vessel meets safety requirements.
These requirements apply to certain vessels engage in commerce. The Coast Guard issues
stickers as proof of compliance with the requirements.
CG Form 5256 contains no PII.

The authority for the issuance of this form is 46 U.S. Code 3305 and 3306.
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

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

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

☐ 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? No, this form does not collect PII.
N/A.
f. Does this form collect Social Security number (SSN) or other element that is standalone Sensitive Personally Identifiable Information (SPII)? No.
☐ 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

Privacy Threshold Analysis – IC/Form

☐ Yes. Please describe how notice is provided.
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

time of collection by
DHS (Does the records
subject have notice of
the collection or is
form filled out by third
party)?

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

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

2

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

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.
N/A
☐ Manually (data elements manually entered).
Please describe.

☐ Automatically. Please describe.
Click here to enter text.
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.
Click here to enter text.
☐ By a non-personal identifier. Please describe.
N/A

The sticker is valid until the certificate expiration
date.

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 records schedule
number.
e. How do you ensure
The sticker is valid until the certificate expiration
that records are
date.
disposed of or deleted
in accordance with
the retention
schedule?
f. Is any of this information shared outside of the original program/office?
☐ No. Information on this form is not shared outside of the collecting office.

☐ 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 sticker is to be displayed on a small passenger vessel in an area visible to the
public, to serve as an advisory that the vessel has successfully underwent a Coast
Guard safety inspection.

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
March 13, 2017
April 4, 2017

☐ Yes. Please include it with this PTA
submission.
X No. Please describe why not.
CG-5256 is not privacy sensitive.

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 5256 (Small Passenger Vessel Inspection sticker) is not privacy sensitive.

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Version number: 04-2016

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

1141495
4/10/17
4/10/20

DESIGNATION
Privacy Sensitive IC or
Form:

No 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:
Click here to enter text.
PTA:
No system PTA required.
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

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.
The DHS Privacy Office finds that the CG-5256 (Small Passenger Vessel Inspection Sticker)
is a non privacy-sensitive collection of information. The sticker serves as proof that a vessel
underwent and passed a safety inspection. No PII is collected in the issuing of a Small
Passenger Vessel Inspection Sticker.

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Version number: 04-2016