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:

Form I-910

Form Title:

Application for Civil Surgeon Designation

Component:

U.S. Citizenship and
Immigration Services
(USCIS)

Office:

Field Operations
Directorate

IF COVERED BY THE PAPERWORK REDUCTION ACT:
Collection Title:
Form I-910, Application for Civil Surgeon Designation
OMB Control
Number:
Collection status:

Name:
Office:
Phone:

Name:
Office:

1615-0114
Revision

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

May 31, 2018
June 30, 2016

PROJECT OR PROGRAM MANAGER
Angela Honer
Field Operations Directorate
Title:
Adjudications Officer
[email protected]
(202)272-1713
Email:
COMPONENT INFORMATION COLLECTION/FORMS CONTACT
Kerstin Jager
PRA Compliance Branch
Title:
MPA

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

Phone:

[email protected]
(202)213-4211
Email:
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.
Section 212(a)(1)(A) of the Immigration and Nationality Act (Act) renders individuals
inadmissible if the individual is afflicted with the statutorily mentioned diseases or
medical conditions (these diseases and conditions include communicable diseases of
public health significance, failure to meet vaccination requirements, mental or physical
disorders with associated harmful behavior, or drug abuse or addiction). In order to
establish that the individual is admissible when seeking adjustment of status to a legal
permanent resident (and in certain cases other aliens seeking an immigration benefit),
the individual must submit Form I-693, Report of Medical Examination and Vaccination
Record, that is completed by a civil surgeon, a USCIS- designated physician.
The statutory basis for the designation of civil surgeons and the medical examination of
aliens is contained in section 232 of the INA and 8 CFR 232.2. To be selected as a civil
surgeon, the physician has to demonstrate that he or she is a licensed physician with no
less than 4 years of professional experience. The National Benefits Center (NBC)
currently adjudicates all requests for civil surgeon designation, which are filed on Form
I-910, Application for Civil Surgeon Designation. Since March 11, 2014, adjudication of
Form I-910 has been centralized at NBC.
USCIS is updating this PTA to include the following changes:
 A-file number (if applicable) added to part 1, page 2, item number 9
 Substantive standard language and renumbering changes made throughout the
form and instructions
 Employment authorization document (EAD) question added to part 3, page 3,
item number 4
 Declaration added to part 7, Page 4, item number 4

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

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 232 of the INA and 8 CFR 232.2

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

☐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:
https://www.uscis.gov/system/files_force/files/form/i910.pdf?download=1

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.
To apply for civil surgeon designation, USCIS requires a civil surgeon to submit the
following information:
• A properly completed and signed Form I-910, with the required fee;
• A copy of a current medical license (for each state in which the physician seeks to
complete immigration medical examinations);
• A copy of each of the physician’s medical degrees, either as a Doctor of Medicine (M.D.)
or as a Doctor of Osteopathy (D.O.);
• Proof of four years of professional experience, excluding any time spent in post-medical
school training. Evidence of professional experience includes, but is not limited to,
evaluations, certificates of completion, business tax returns or business licenses (for selfemployed physicians), or letters of employment verification; and
• Proof of employment authorization it the United States.
The Form I-910 collects the following required data:
First, middle and last name; date of birth; gender; USCIS ELIS account number (if any);
Civil Surgeon Identification Number (CSID) (if any); the physician’s clinical office
location(s); medical school and degree information; state medical license information;
immigration status in the United States; and proof of four years of professional
experience, including the names and contact information of the physician’s employers.

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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 Form I-910 also collects the following optional data about the physician’s medical
practice where he or she intends to perform medical examinations: email address,
website address, acceptable means of payment, accepted medical insurance plans;
languages spoken; office hours; handicap accessibility; and an “other” blank that allows
the physician to include any other office information that might be helpful to the public.
This information will be included in the Civil Surgeon Locator (now Find a Doctor) in the
future to assist applicants in searching for a civil surgeon.
This data collection is necessary to determine whether a physician meets the statutory
and regulatory requirements for civil surgeon designation. For example, for all
documents are reviewed to determine whether the physician has a currently valid
medical license or and whether the physician has had any action taken against him or her
by the medical licensing authority of the state.
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 Entry,
☒ Passport Number
Pre-Check, etc.)
☐ Bank Account, Credit Card, or
☐ Driver’s License Number
other financial account number
☐ Biometrics
☐ Other. Please list: CSID number
g. List the specific authority to collect SSN or these other SPII elements.
Section 232 of the INA and 8 CFR 232.2 allows USCIS to collect SPII in order to adjudicate
the Form I-910.

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.
This data collection is necessary to determine whether a physician meets the statutory
and regulatory requirements for civil surgeon designation. All documents are reviewed
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Privacy Office
U.S. Department of Homeland Security
Washington, DC 20528
202-343-1717, [email protected]
www.dhs.gov/privacy

to determine whether the physician has a currently valid medical license or and whether
the physician has had any action taken against him or her by the medical licensing
authority of the state.
i. Are individuals
☒ Yes. Please describe how notice is provided.
provided notice at
Yes, an acknowledgement of receipt notice is
the time of
provided by the Lockbox as well as an acceptance or
collection by DHS
rejection letter from NBC is provided. Furthermore,
(Does the records
USCIS provides a Privacy Notice to the individual on
subject have notice
the form instructions prior to collecting any
of the collection or
information.
is form filled out by
☐No.
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.
NPWR
☒ Scanned forms (completed forms are scanned into
an electronic repository). Please describe the
electronic repository.
National Benefits Center Processing Workflow
Repository (NPWR)
b. If electronic, how
does DHS input the
responses into the IT
system?

☒ Manually (data elements manually entered). Please
describe. Data input by contractors and signature
page is scanned in.
☐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.
Receipt numbers are generated with a “CSD”
prefix and uploaded into National File Tracking
System (NFTS), and a unique CS Identification
Number (CSID) is generated for each civil surgeon
applicant.
☐By a non-personal identifier. Please describe.
Click here to enter text.

Paper files are stored for 35 years at Harrisonburg (HBG)
d. What is the records
in accordance with DAA-0566-2014-0001
retention
schedule(s)? Include
the records schedule
number.
e. How do you ensure
Harrisonburg personnel are responsible for ensuring
that records are
the records are disposed of once the 35 year records
disposed of or deleted
retention schedule has been met
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.
USCIS does not routinely share information with other DHS components to designate
physicians as civil surgeons. However, in the event USCIS suspects a physician of
fraud, USCIS will forward the case to ICE for potential criminal investigation.

☐Yes, information is shared external to DHS with other federal agencies, state/local
partners, international partners, or non-governmental entities. Please describe.
USCIS does not routinely share information with external components. However,
USCIS may share this information with the Department of Health and Human Services
(HHS) during the course of the civil surgeon application process as required by law

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

and pursuant to Routine Use Q in the DHS/USCIS-007 Benefits Information System
SORN.
☐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:

Catherine Shorten

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

January 5, 2018

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.)

January 10, 2018
☒ 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.
The USCIS Office of Privacy recommendation is to designate Form I-910 as a privacy
sensitive form with coverage under the following:
PIAs
• Civil Surgeon Designation PIA, which covers the information collected through the Form
I-910, used, and maintained by the respective IT systems
• myUSCIS PIA, which covers the Find a Civil Surgeon locator.
SORNs
• DHS/USCIS-007 BIS SORN, which USCIS updated to cover the collection, use, and
maintenance of civil surgeon data
USCIS has converted the previous Privacy Act Statement to a Privacy Notice.

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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:

Kameron Cox

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

1156149
January 10, 2018
January 10, 2021

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 approved this ICR/Form.

Date IC/Form Approved January 10, 2018
by PRIV:
IC/Form PCTS Number: Click here to enter text.
Privacy Act
New e(3) statement is required.
Statement:
Privacy Notice is sufficient
PTA:
NPWR PTA is adequate
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/USCIS/PIA-064 myUSCIS
DHS/USCIS/PIA-067 Civil Surgeon Designation
SORN:
System covered by existing SORN
If covered by existing SORN, please list: DHS/USCIS-007 Benefits
Information System October 19, 2016 81 FR 72069
DHS Privacy Office Comments:
Please describe rationale for privacy compliance determination above.
USCIS is submitting this PTA to update Form I-910, Application for Civil Service Designation,
to include the A-number, Employment Authorization Documentation, and other
substantive information to the form. Form I-910 is used by physicians to be selected as a
civil surgeon that can then conduct medical examinations on applicants for immigration
benefits. The physician has to demonstrate that he or she is a licensed physician with no
less than 4 years of professional experience.
The DHS Privacy Office (PRIV) agrees with USCIS Privacy that Form I-910 is a privacy
sensitive information collection requiring PIA coverage because it collects PII from
members of the public. PRIV finds that DHS/USCIS/PIA-067 Civil Surgeon Designation
assesses the risks surrounding the collection, use, and adjudication of the physician’s
information for purposes of accrediting the physician as a civil surgeon. DHS/USCIS/PIA064 myUSCIS covers the use of physician office location information for use on the online
“find a doctor” application.
Form I-910 requires SORN coverage because it collects information that is retrieved by a
unique identifier. PRIV concludes that DHS/USCIS-007 covers the collection of physician
information for the purposes of assisting in the processing of immigration benefits.
PRIV further finds that Form I-910 requires a privacy notice because it may collect PII from
non-US persons that would then be entered into a system of records.

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