PTA for Request for Fire Management Assistance Declaration

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:

Form Number(s): FEMA Form 078-0-1
Request for Fire Management Assistance Declaration
Federal Emergency
Office:
Office of Response and
Management Agency
Recovery
(FEMA)

IF COVERED BY THE PAPERWORK REDUCTION ACT:
Collection Title:
Fire Management Assistance Grant Program
1660 - 0058
OMB Control
OMB Expiration
January 31, 2018
Number:
Date:
Collection status:
Extension
Date of last PTA (if
July 2, 2014
applicable):

Name:
Office:
Phone:

Name:
Office:

PROJECT OR PROGRAM MANAGER
Allen Wineland
Public Assistance Division
Title:
FMAG Program Manager
202-702-1472
Email:
[email protected]

COMPONENT INFORMATION COLLECTION/FORMS CONTACT
Millicent Brown
Records Management Branch,
Sr. Forms Management &
Title:
Information Management Division

Phone:

Information Collections Analyst

[email protected]
Email:
SPECIFIC IC/Forms PTA QUESTIONS

(202) 212-7014

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

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.
FEMA Form 078-0-1, Request for a Fire Management Assistance Declaration (FMAG) is
used by the State to provide information in support of its request for a fire management
assistance declaration. This form must be completed by the Governor or Governor’s
Authorized Representative (GAR) and forwarded to the appropriate FEMA Regional Director
for review and transmittal to FEMA headquarters.
The information is required in order for a State to receive a Fire Management Assistance
Declaration which if approved, will make the State eligible for an FMAG grant, which
provides financial assistance to States after a fire-related incident, if the other terms and
conditions of the FMAG program are met. The form captures the name of Governor of the
State or the (GAR). The form also capture the phone number of the person signing the form
(the Governor or the GAR), and the name and address of the agency represented. Finally, it
capture the signature and title of the person completing the form.
The form contains other non-PII information and data regarding the severity of the wildland
fire that is under consideration for an FMAG declaration. The information includes the
location and size of the fire, current and projected wind speed and direction, temperature,
proximity of nearby communities, any ordered evacuations, and the number of people
evacuated. Additional data and information includes any potential economic impact, any
threatened structures, including bridges, railroads, powerlines, power plants, and threatened
natural recourse, such as sources of drinking water, environmental and cultural resources. It
also includes the number of wild fires currently burning in the State and the level of state
resources committed to fire fighting.
Follow-up information related to the fire-related incident (not PII) may be furnished by the
State or requested by FEMA after the initial request has been received. For example, if the
extent or threat of the fire is not fully stated in the FF 078-0-1, FEMA may request additional
information about the fire in the initial request to make an eligibility determination. This
information is provided upon each approval of a fire management assistance declaration.
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.

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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 Federal Emergency Management Agency working through its 10 regions under the
provisions of Section 420 of the Robert T. Stafford Disaster Relief and Emergency
Assistance Act, 42, U.S.C 5187, as amended by § 303 of the Disaster Mitigation Act of
2000, uses these forms to collection information needed to make fire severity declaration
and grant eligibility decisions for States, local governments and tribal governments.
Also, 2 CFR part 200 provides authority for the collection.

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.

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.

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.

☐ Other individual/entity/organization that is NOT
the record subject. Please describe.
☒ 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.
Governor/Governor’s Representative (GAR):
 Name of governor or GAR;
 Title;
 Signature of submitter;
 Day (work) and night (personal) phone numbers of governor or GAR; and
 Address of agency.
FEMA Personnel:
 Signature
 Title
State Personnel:
 Signature
Forestry Personnel:
 Signature
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.)
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Privacy Office
U.S. Department of Homeland Security
Washington, DC 20528
202-343-1717, [email protected]
www.dhs.gov/privacy

☐ Bank Account, Credit Card, or other
financial account number
☐ Other. Please list:

☐ 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
☒ Yes. Please describe how notice is provided.
provided notice at the
A privacy notice is included on the latest draft of
time of collection by
the form.
DHS (Does the records
☐ No.
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,
The forms are stored in file cabinets at regional
completed IC/forms?
and Headquarters offices.
☒ Electronic. Please describe the IT system that will
store the data from the form.
The forms are stored both electronically and in file
cabinets at regional and Headquarters Offices. The
electronic forms are stored in FEMA’s grant management
system database (EMMIE).
☐ Scanned forms (completed forms are scanned into
an electronic repository). Please describe the
electronic repository.
b. If electronic, how
does DHS input the
Privacy Threshold Analysis – IC/Form

☒ Manually (data elements manually entered). Please
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

responses into the IT
system?

Selected data is captured via a keyboard entry
from a paper copy of the form Date elements that
may be provided include the name, and day and
night telephone numbers of the requesting official
on behalf of the agency they represent.
☐ 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.
The information is accessed in EMMIE by FMAG
declaration number and/or a specific Project
Worksheet associated with an FMAG declaration.
DAP 4-2-1: TEMPORARY. Cut off when termination
memorandum is approved. Retire to FRC 1 year after
cutoff. Destroy 6 years 3 months after cutoff.

d. What is the records
retention
schedule(s)? Include
the records schedule
number.
e. How do you ensure
Managers and staff at each regional office and HQ
that records are
office have the primary responsibility to ensure
disposed of or deleted
records are disposed, deleted, and preserved in
in accordance with
accordance with DAP 4-2-1.
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.

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

☐ 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:

Heather K. Mills

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

July 27, 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.)

July 31, 2017
☒ Yes. Please include it with this PTA
submission.
☐ No. Please describe why not.
Click here to enter text.

Component Privacy Office Recommendation:
Please include recommendation below, including what existing privacy compliance
documentation is available or new privacy compliance documentation is needed.
SORN Coverage:
 DHS/FEMA – 009 Hazard Mitigation Disaster Public Assistance and Disaster Loan
Programs, 79 Fed. Reg. 16,015 (March 24, 2014).
PIA Coverage:
DHS/FEMA/PIA – 013 Grant Management Programs (February 19, 2015).

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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:

Hannah Burgess

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

1148982
September 6, 2017
September 6, 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 commented on this ICR/Form.

Date IC/Form Approved August 23, 2017
by PRIV:
IC/Form PCTS Number: FEMA Form 078-0-1
Privacy Act
New e(3) statement is required.
Statement:
Privacy Notice Form 1660-058 FF 078-0-1
PTA:
New 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/FEMA/PIA – 013 Grant
Management Programs
If a PIA update is required, please list: Click here to enter text.
SORN:
If covered by existing SORN, please list:
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.
FEMA Form 078-0-1, Request for a Fire Management Assistance Declaration (FMAG) is
used by the State to provide information in support of its request for a fire management
assistance declaration. The form is must be completed by the Governor or Governor’s
Authorized Representative (GAR) and forwarded to the appropriate FEMA Regional
Director for review and transmittal to FEMA headquarters.
The Privacy Office finds that the form is privacy sensitive and a PIA is required because
FEMA collects information from members of the public, specifically the governor or their
representative. PIA coverage is provided by DHS/FEMA/PIA – 013 Grant Management
Program, which details FEMA’s collection of PII as part of the grant application process.
The DHS Privacy Office also finds that no SORN is required, since information is not
retrieved by personal identifier. A Privacy Notice, however, is required because the form
collects PII from federal employees or contractors. The Privacy Notice for this form was
submitted and approved along with this PTA.

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