PTA FEMA Form 009-0-134

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:

009-0-134

Form Title:

Disaster Assistance Recertification Worksheet

Component:

Federal Emergency
Management Agency
(FEMA)

Office:

ORR

IF COVERED BY THE PAPERWORK REDUCTION ACT:
Collection Title:
Direct Housing Program Forms
OMB Control
Number:
Collection status:

Name:
Office:
Phone:

Name:

1660-0138
Extension

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

August 31, 2018
April 30, 2015

PROJECT OR PROGRAM MANAGER
Brian G. Thompson
ORR
Title:
Unit Chief
540-686-3602
Email:
[email protected]
s.gov
COMPONENT INFORMATION COLLECTION/FORMS CONTACT
Elizabeth McDowell

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

Office:
Phone:

ORR

Title:

Supervisory Program
Specialist
540-686-3630
Email:
[email protected]
hs.gov
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.
The purpose of information collection request (ICR) 1660-0138 is to support the direct
housing operation. The information collected is necessary to determine the feasibility of
a potential site for placement of a Temporary Housing Unit (THU), to ensure the THU is
ready for applicant occupancy, and to confirm applicant understanding of the
requirements of occupancy of the THUs. This information is collected via paper forms,
then uploaded into the Housing Operations Management Enterprise Systems (HOMES)
database used to coordinate the provision of THUs for disaster survivors. HOMES is
located within NEMIS- IA, the Individual Assistance IT System which maintains the
Individuals and Households Program information.
FEMA requires all THU occupants to participate in a recertification process to ensure
they are taking all actions necessary to achieve their Permanent Housing Plan (PHP). The
PHP requires the occupant to demonstrate they are either attempting to repair or rebuild
their pre-disaster residence, are attempting to purchase a new residence that is
habitable, or are attempting to find and lease a rental unit. As part of the recertification
process, the occupants are required to meet with a FEMA employee on a regular basis to
show they are taking all actions necessary to achieve their PHP.
During this meeting with a FEMA employee, FEMA Form 009-0-134, Recertification
Worksheet, is used to document the occupant's PHP and their progress toward achieving
permanent housing. The form captures key data used to determine if they are meeting
their PHP such as rental resources they have attempted to use, if applicable, and a repair
progress checklist indicating the status of any repairs that were needed to the damaged
dwelling. The FEMA representative completes the Recertification Checklist portion of the
form to document all required steps of the recertification process were completed. The
data and checklist are then evaluated by the FEMA representative to either approve or
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Privacy Office
U.S. Department of Homeland Security
Washington, DC 20528
202-343-1717, [email protected]
www.dhs.gov/privacy

deny the recertification.
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.
The Robert T. Stafford Disaster Relief and Emergency Assistance Act, as amended, 42
U.S.C. § 5174 and Title 44 C.F.R. Part 206.117

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.)

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
☐ 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:

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.
 Applicant name
 Applicant Registration ID number
 Applicant’s THU address
 Applicant’s damaged dwelling address
 Applicant phone number
 Name of each person living in unit
 Sex of each person living in unit
 Age of each person living in unit
 Household income of each applicant over the age of 18
 Name of co-applicant, if applicable
 Disaster number
 MHU (Manufactured Housing Unit) Vehicle Identification Number
 MHU (Manufactured Housing Unit) Barcode
 Pre-disaster housing cost (renters only)
 Pre-Disaster utilities cost
 Contractor’s name
 Contractor’s address
 Contractor’s phone number
 Pre-disaster HUD section 8 status
 Rental Property Resources (Up to 4 rental properties may be identified on the
form.):
o Address
o Contact’s name
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Privacy Office
U.S. Department of Homeland Security
Washington, DC 20528
202-343-1717, [email protected]
www.dhs.gov/privacy







o Monthly rent
FEMA Recertification caseworker’s name
FEMA Housing group supervisor signature
Name of the occupant/applicant present during the recertification inspection
Relationship to the applicant
Pictures of the inside and outside of the damaged dwelling (pre-disaster owners
only)

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

Privacy Threshold Analysis – IC/Form

☒ Yes. Please describe how notice is provided.
A Privacy Notice is provided on the first page of
the form.
☐ No.

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

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
store the data from the form.
The form is stored in the HOMES database within
NEMIS-IA as part of the applicant’s file.
☒ Scanned forms (completed forms are scanned into
an electronic repository). Please describe the
electronic repository.
The form is scanned and uploaded into the
HOMES database within NEMIS-IA.
b. If electronic, how
does DHS input the
responses into the IT
system?

☐ Manually (data elements manually entered). Please
describe.
Click here to enter text.
☒ Automatically. Please describe.
The form is scanned and uploaded by JFO staff
into the HOMES database within NEMIS-IA.

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.
Applicant name, Applicant Registration ID,
Applicant damaged dwelling address
☐ By a non-personal identifier. Please describe.
Click here to enter text.
Disaster assistance request information will be
retained in accordance with the National Archives and
Records Administration’s (NARA) record retention
schedule and FEMA’s Records Schedule N1-311-86-1,
item 4C10a.

d. What is the records
retention
schedule(s)? Include
the records schedule
number.
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
The program adheres to the disposition schedule
that records are
which provides timeframes for records destruction
disposed of or deleted
and/or disposal of relevant documents associated
in accordance with
with the program.
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.

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:

November 17, 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.)

December 5, 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:
 DHS/FEMA – 008 Disaster Recovery Assistance Files, 78 Fed. Reg. 25,282 (April 30,
2013).
PIA:
 DHS/FEMA/PIA – 027 National Emergency Management Information System Individual Assistance (NEMIS-IA) Web-based and Client-based Modules (June 29,
2012).
 Forthcoming DHS/FEMA/PIA XXX Individual Assistance Program

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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

1155142
December 15, 2017
December 15, 2018

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
Choose an item.
Statement:
Privacy Notice submitted and approved
PTA:
Choose an item.
Click here to enter text.
PIA:
PIA in progress
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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: Forthcoming Individual
Assistance PIA
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/FEMA-008 Disaster
Recovery Assistance Files April 30, 2013 78 FR 25282
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 is submitting this PTA to discuss the Disaster Assistance Recertification
Worksheet Form (FF 009-0-134). This form is part of OMB ICR 1660-0138, the
purpose of which is to support direct housing. When a disaster survivor is deemed
eligible for a housing unit, FEMA uses the forms in this information collection to
determine the feasibility of a potential site for temporary housing, to ensure the
housing unit is ready for occupancy, and to confirm applicant understanding of
requirements.
FEMA uses this form to document an occupant’s progress towards achieving
permanent housing, including attempts to repair their pre-disaster residence,
attempting to find a rental unit, or attempting to purchase a new residence. This is
part of the disaster assistance recertification process. Form 009-0-134 collects
applicant name and contact information, household income information and
name/age of occupants, contractor name and contract information. The form also
collects the name and signature of a FEMA caseworker and housing group
supervisor.
The DHS Privacy Office agrees that form 009-0-134 is a privacy-sensitive collection
that collects PII from members of the public and FEMA employees/contractors,
requiring PIA coverage. Coverage is provided by the forthcoming Individual
Assistance PIA, which will cover all aspects of the Individual Assistance program,
including collection of PII in order to provide direct housing for disaster survivors.
SORN coverage is also required because information is retrieved by personal
identifier. Coverage is provided by DHS/FEMA-008 Disaster Recovery Assistance
Files, which covers information collected in order to provide disaster assistance to
applicants.
This PTA expires in one year. Two additional years of coverage will be provided
upon completion of the Individual Assistance PIA.

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