1625-0012 Privacy Threshold Analysis (PTA) IC and Forms

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:

CG-718A

Form Title:

Certificate of Discharge to Merchant Mariner

Component:

U.S. Coast Guard (USCG) Office:

National Maritime Center
(NMC)

IF COVERED BY THE PAPERWORK REDUCTION ACT:
Certificate of Discharge to Merchant Mariner
Collection Title:
OMB Control
Number:
Collection status:

Name:
Office:
Phone:

Name:
Office:
Phone:

1625-0012
Revision

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

May 31, 2018
N/A

PROJECT OR PROGRAM MANAGER
Michael P. Toth
NMC 4-1
Branch Chief
Title:
304-433-3729
[email protected]
Email:
COMPONENT INFORMATION COLLECTION/FORMS CONTACT
Anthony Smith
CG-612
PRA Manager
Title:
202-473-3532
[email protected]
Email:

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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 information is used on an as needed basis by mariners and the U.S. Coast Guard to
establish sea service and qualifications for issuance of a Merchant Mariner Credential (MMC)
or additional endorsements issued by the U.S. Coast Guard. This information is also used for
claims against employers, medical claims, qualifying for retirement and/or insurance benefits,
and provides the U.S. Maritime Administration (MARAD) on the availability of mariners in
time of national emergency. If the information is not gathered, the U.S. Coast Guard would
not be able to determine if the mariner meets the required sea time, in accordance with the
Code of Federal Regulations (CFR), for the credential the individual is applying for.
The authority for this collection is Title 46 United States Code (U.S.C.) § 10311; Title 46 CFR
Part 14.

2. Describe the IC/Form
a. Does this
☒ Yes
form collect
☐ No
any
Personally
Identifiable
Information”
(PII1)?
b. From which
☒ Members of the public
type(s) of
☒ U.S. citizens or lawful permanent residents
individuals
☒ Non-U.S. Persons.
does this
☐ DHS Employees
form collect
☐ DHS Contractors
information?
☒ Other federal employees or contractors.
(Check all that
apply.)
c. Who will
☐The record subject of the form (e.g., the individual
complete and
applicant).
submit this
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

form? (Check
all that
apply.)

☐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.
Title 46 CFR Part 14.301 requires each master or individual in
charge of a vessel, when Shipping Articles are required, to
prepare a Certificate of Discharge for each merchant mariner
being discharged.

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:
http://www.dco.uscg.mil/Portals/9/NMC/pdfs/forms/CG_718A.pdf

e. What information will DHS collect on the form?
Mariner’s name, mariner’s citizenship, mariner’s reference number, mariner’s credential
number, master’s name in signatory, and master’s reference number.

f. Does this form collect Social Security number (SSN) or other element that is
stand-alone Sensitive Personally Identifiable Information (SPII)? No
Check all that apply.
☐ Social Security number
☐ DHS Electronic Data Interchange Personal
Identifier (EDIPI)
☐ Alien Number (A☐ Social Media Handle/ID
Number)
☐ Known Traveler Number
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Privacy Office
U.S. Department of Homeland Security
Washington, DC 20528
202-343-1717, [email protected]
www.dhs.gov/privacy

☐ Tax Identification
Number
☐ Visa Number
☐ Passport Number
☐ Bank Account, Credit
Card, or other financial
account number
☐ Other. Please list:

☐ Trusted Traveler Number (Global Entry, PreCheck, 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.
The Privacy Act statement is on the form. Further notice is provided
to individuals via a System of Records, Federal Register Volume 74,
Number 121 (Thursday, June 25, 2009), pages 30308-30311.
☐ No.

3. How will DHS store the IC/form responses?

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

a. How will DHS store
the original,
completed IC/forms?

☒ Paper. Please describe.
In accordance with Title 46 CFR Part 14, Subpart C,
one hard copy of the form CG-718A is given to the
discharged mariner who may submit the information
to the U.S. Coast Guard NMC as evidence of sea
service to show eligibility for an original, renewed, or
upgraded Merchant Mariner Credential. If the
mariner submits his copy with his application then
the hard copy is retained with the mariner's
application file.
☒ Electronic. Please describe the IT system that will
store the data from the form.
The U.S. Coast Guard enters the data from the CG718A into the Merchant Mariner Licensing and
Documentation (MMLD) database system for use
during the mariners’ next credential application
evaluation.
☐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.
The following data elements are entered into MMLD
database: Citizenship, rating (capacity in which
employed), place of shipment, date of shipment,
place of discharge, date of discharge, vessel name,
vessel official number, vessel class, operating
company, and the nature of the voyage.
☐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.
This form CG-718A already includes a Privacy Act
Statement that will be updated. The U.S. Coast
Guard enters the data elements from the CG-718A
into MMLD database system, within which the
mariner is assigned a Reference Number as a
personal identifier for retrieval of the mariner’s
record and for use during the mariner’s next
credential application evaluation.
☐By a non-personal identifier. Please describe.

d. What is the records
retention
schedule(s)? Include
the records schedule
number.

Click here to enter text.
Paper records related to issuance of Merchant Mariner
Credentials are held on site for one (1) year past the last
activity with the file. After that time, records are then
transferred to the Washington National Records Center in
Suitland, MD. Electronic records are stored on a secure
database server at the Coast Guard Operations Systems
Center (OSC).
The form CG-718A falls under our Records Disposition
Authority, Item 1D, for Records for Merchant Mariners
Licensed 1968-Present for whom the USCG does not
issue a DD 214, Report of Separation from Military
Service. This includes paper records, microfilm copies,
and records in the MMLD system or equivalent. The
disposition for these records is Temporary and to be
destroyed 75 years after cutoff.
Records Disposition Authority SF-115
NARA Job Number: N1-026-08-5

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

e. How do you ensure
that records are
disposed of or deleted
in accordance with
the retention
schedule?

If the file is entered/scanned into the MMLD system, the
paper file may be destroyed upon verification. Once the
form CG-718A is entered into MMLD for records
storage and the information is verified, the copy mailed
to the NMC by the operating company is destroyed by
industrial shredders.

Upon issuance of a Destruction Notice by NARA after
75 years, the U.S. Coast Guard will grant permission for
destruction of the paper records, which may include a
copy of the form CG-718A submitted by the mariner.
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.
☒ 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:

Robert Herrick

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

March 13, 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.)

Click here to enter a date.
☒ Yes. Please include it with this PTA
submission. The PAS will be updated.
☐No. Please describe why not.
Click here to enter text.

Component Privacy Office Recommendation:
The Certificate of Discharge to Merchant Mariner information collection is used on an as needed
basis by mariners and the U.S. Coast Guard to establish sea service and qualifications for
issuance of a Merchant Mariner Credential (MMC) or additional endorsements issued by the
U.S. Coast Guard. This information is also used for claims against employers, medical claims,
qualifying for retirement and/or insurance benefits, and provides the U.S. Maritime
Administration (MARAD) on the availability of mariners in time of national emergency.
The form collects the following information: Mariner’s name, mariner’s citizenship, mariner’s
reference number, mariner’s credential number, master’s name in signatory, and master’s
reference number.
DHS/USCG/PIA-015 Merchant Mariner Licensing and Documentation System and DHS/USCG030 Merchant Seamen’s Records provide coverage for this collection.

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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:

Riley Dean

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

Click here to enter text.
May 30, 2018
May 30, 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:

Choose an item.

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 update is required.
Statement:
PRIV will work with USCG as needed to update the Privacy Act
Statement.
PTA:
Choose an item.
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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-015 Merchant
Mariner Licensing and Documentation System (MMLDS)
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-030 Merchant
Seamen's Records
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.
USCG is submitting this PTA to discuss form CG-718A (Certificate of Discharge to
Merchant Mariner), which is associated with OMB Control Number 1625-0012.The
information collected from this form is used by mariners and USCG to establish sea
service and qualifications for issuance of a Merchant Mariner Credential (MMC) or
additional endorsements issued by USCG. The information is also used for claims
against employers, medical claims, qualifying for retirement and/or insurance
benefits, and provides the U.S. Maritime Administration (MARAD) on the availability
of mariners in time of national emergency.
USCG enters the data from form CG-718A into the Merchant Mariner Licensing and
Documentation (MMLD) database system. No information on this form is shared
outside of the collecting office.
The DHS Privacy Office finds that this form is privacy-sensitive, requiring PIA and
SORN coverage.
PIA coverage is provided by DHS/USCG/PIA-015 Merchant Mariner Licensing and
Documentation System, which specifically outlines the MMLD system and the
information it collects.
SORN coverage is provided by DHS/USCG-030 Merchant Seamen's Records, which
allows for the collection of information in order to administer the Commercial Vessel
Safety Program to determine domestic and international qualifications for the
issuance of licenses, documents, and staff officer certifications. This includes
establishing eligibility of a merchant mariner's document, duplicate documents, or
additional endorsements issued by USCG.
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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 DHS Privacy Office will assist USCG in updating the Privacy Act Statement for this
form as needed.

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