1625-0002 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:
Form Title:
Component:

CG-2633

Application for Waiver and Waiver Order
U.S. Coast Guard (USCG)

Office:

CG-REG

IF COVERED BY THE PAPERWORK REDUCTION ACT:
Collection Title:
Applications for Vessel Inspection, Waiver, and Continuous Synopsis
Record
OMB Control
1625-0002
OMB Expiration
June 30, 2017
Number:
Date:
Collection status:
Extension
Date of last PTA (if
N/A
applicable):
Name:
Office:
Phone:

Name:
Office:
Phone:

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 Manager
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 is to document an application for waiver. An application is voluntary
and is only submitted when a vessel owner/operator desires a waiver from the navigation and
vessel inspection requirements. The Coast Guard promulgated regulations to protect life,
property, and the environment. This voluntary reporting requirement is part of the Coast Guard’s
Marine Safety Program.
CG Form 2633 contains basic business contact information which may include the name and
address of the vessel owner/operator, if owned/operated by an individual.

The authority to receive this information is 46 U.S. Code 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.

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.

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.

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?
Basic business contact information (i.e. vessel characteristics, name/address of vessel
owner/operator, and signature of applicant).
f. Does this form collect Social Security number (SSN) or other element that is standalone 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

h. How will this information be used? What is the purpose of the collection? Describe

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

why this collection of SPII is the minimum amount of information necessary to
accomplish the purpose of the program.
The form is used to document the request for waiver from the navigation and vessel
inspection requirements.
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.
The Application For Waiver and Waiver Order (CG2633) contains a Privacy Act Statement.
☐ 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?

Privacy Threshold Analysis – IC/Form

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.
Forms that the Coast Guard receive are
maintained in Marine Information for Safety and Law
Enforcement (MISLE) database.
Manually (data elements manually entered).
Please describe.
A scanned form is uploaded to the vessel-specific
file in MISLE.
☐ 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.
Click here to enter text.
By a non-personal identifier.
A search is accomplished using vessel-specific
information.
A record is retained for the life of the vessel; NARA
retention schedule number N1-026-05-015.

d. What is the records
retention
schedule(s)? Include
the records schedule
number.
e. How do you ensure
As records are maintained in the MISLE database,
that records are
disposal/deletion is in accordance with the business
disposed of or deleted
rules for the database.
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.
Click here to enter text.
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

February 10, 2017
April 6, 2017

X Yes. Please include it with this PTA
submission.
☐ No. Please describe why not.
Click here to enter text.

Component Privacy Office Recommendation:
The Plan Approval and Records for Subdivision and Stability Regulations -- Title 46 CFR
Subchapter S (1625-0002) collects basic business contact information (i.e. vessel
characteristics, name/address of vessel owner/operator, and signature of applicant) from vessel
owners/operators that request a waiver from navigation and vessel inspection requirements.
This collection of information is covered under DHS/USCG/PIA-008 and DHS/USCG-013.

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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

1141502
4/10/17
4/10/20

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:
Click here to enter text.
PTA:
No system PTA required.
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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:
System covered by existing PIA
If covered by existing PIA, please list:
DHS/USCG/PIA-008 Marine Information for Safety and Law
Enforcement (MISLE)
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-013 - Marine Information for Safety and Law Enforcement
(MISLE)
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 CG 2633 (Application for Waiver and Waiver Order) is a
privacy-sensitive collection. The application is used by vessel owners/operators to request
a waiver for navigation and vessel inspection requirements. The form collects basic business
contact information, which may include the name and address of the vessel owner/operator, if it
is owned/operated by an individual.
The Privacy Office finds that PIA coverage is provided by DHS/USCG/PIA-008 Marine
Information for Safety and Law Enforcement (MISLE), which assess the privacy risks
associated with the Coast Guard’s use of PII in support of marine safety, security,
environmental protection and law enforcement programs. PRIV also finds that SORN
coverage is provided by DHS/USCG-013 - Marine Information for Safety and Law
Enforcement (MISLE), which outlines the Coast Guard’s collection and maintenance of
information in order to establish a safety, security and law enforcement performance
history of vessels, facilities, people and organizations engaged in marine transportation,
including enforcement action, that can be used to identify and address safety, security and
environmental risks and to establish vessel eligibility for documentation as a U.S. flag
vessel.

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