1625-0094 Privacy Threshold Analysis (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

Version number: 04-2016
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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-4602B

Form Title:

Cargo Record Book for Ships Carrying Noxious Liquid Substances in
Bulk
U.S. Coast Guard (USCG) Office:
CG-REG

Component:

IF COVERED BY THE PAPERWORK REDUCTION ACT:
Collection Title:

Ships Carrying Bulk Hazardous Liquids

OMB Control
Number:
Collection status:

1625-0094

Name:
Office:
Phone:

Name:
Office:
Phone:

Extension

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

August 31, 2018
N/A

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. Anthony Smith
CG-612
Title:
PRA Coordinator
202-475-3532
Email:
[email protected]

Privacy Threshold Analysis – IC/Form

Version number: 04-2016
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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 (CG-4602B) is to document cargo and ballast transfers on
chemical tank vessels. The information is used by the Coast Guard to determine
compliance with environmental standards. The form is maintained on the vessel and is
reviewed during Coast Guard inspections.
Form CG-4602B contains vessel-specific information-it does not collect PII.
The authority for this collection is 46 U.S.C. 3703.

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?

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.
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

☐ Yes
☐No
☐Law enforcement.
☐DHS employee or contractor.
☐Other individual/entity/organization that is
NOT the record subject. Please describe.
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?
The form does not collect PII.
f. Does this form collect Social Security number (SSN) or other element that is standalone Sensitive Personally Identifiable Information (SPII)? No.
☐ 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
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

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.
No. The form is not submitted to the Coast Guard,
rather it is maintained on the vessel.

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.
Click here to enter text.
☐Scanned forms (completed forms are scanned into
an electronic repository). Please describe the
electronic repository.
N/A
b. If electronic, how
does DHS input the
responses into the IT
system?

☐Manually (data elements manually entered). Please
describe.
☐Automatically. Please describe.
N/A

c. How would a user
search the
information
submitted on the
forms, i.e., how is the

☐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.

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.
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

information
retrieved?

☐ By a non-personal identifier. Please describe.
N/A
The form is not submitted to the Coast Guard, rather
it is maintained on the vessel.

d. What is the records
retention
schedule(s)? Include
the records schedule
number.
e. How do you ensure
The form is not submitted to the Coast Guard, rather
that records are
it is maintained on the vessel. Title 46 CFR 153.909
disposed of or deleted
required that the vessel owner/operator maintain the
in accordance with
form for at least 3-years after the last entry.
the retention
schedule?
f. Is any of this information shared outside of the original program/office?
No. Information on this form is not shared outside of the collecting office.
☐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 include a copy of the referenced form and Privacy Act Statement (if
applicable) with this PTA upon submission.

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 REVIEW
(TO BE COMPLETED BY COMPONENT PRIVACY OFFICE)
Component Privacy Office
Reviewer:

Kenlinishia Tyler

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.)

July 24, 2018
July 25, 2018
☐Yes. Please include it with this PTA
submission.
X☐No. Please describe why not.

Component Privacy Office Recommendation:
Please include recommendation below, including what existing privacy compliance
documentation is available or new privacy compliance documentation is needed.
The Form (4602B) Cargo Record Book for Ships Carrying Noxious Liquid Substances in
Bulk is not a privacy sensitive form.
Vessel specific information is covered by DHS/USCG/PIA-008 Marine Information for
Safety and Law Enforcement (MISLE) and DHS/USCG-013 Marine Information for Safety
and Law Enforcement (MISLE).

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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.
August 10, 2018
August 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.
X 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 by PRIV:
IC/Form PCTS
Number:

Click here to enter a date.
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

Privacy Act
Statement:
PTA:

Non required

Choose an item.
Click here to enter text.
PIA:
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:
Choose an item.
If covered by existing SORN, please list: Click here to enter text.
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 the Cargo Record Book for Ships Carrying Noxious
Liquid Substances in Bulk, Form CG-4602B, which is associated with the Ships Carrying
Bulk Hazardous Liquids information collection and OMB Control Number 1625-0094. The
information collection and recordkeeping requirements required under this OMB Control
Number is implemented in 46 CFR 153 and required by Annex II to the MARPOL
Convention, which is in 46 CFR 153 under the authority of 33 USC 1903. The information is
used by the Coast Guard to evaluate vessel design, to ensure compliance with the
regulations. The information is used by vessel crewmembers in operations related to the
cargoes and to avoid potential dangers presented by the cargo. These requirements are
necessary to ensure that the requirements for the safe transport by vessel of bulk liquid
hazardous materials mandated by 46 USC 3703 are met.
The Cargo Record Book is completed by a vessel crewmember and is maintained on the
vessel. The only PII used on this form is that of the master of the vessel. The form is not
submitted to UCGS, and it is not signed off by USCG. The reviewer is a USCG member
during an inspection. The form and information are not put into the Marine Information for
Safety and Law Enforcement (MISLE) database.
The only PII collected on this form is that of a master of a vessel and that information is not
collected by USCG. PIA coverage for this type of information being required is provided by
DHS/USCG/PIA-008 MISLE, which outlines the risks of capturing information required to
support the Coast Guard’s marine safety, security, environmental protection and law
enforcement programs. SORN coverage is not technically required as the information is
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Privacy Office
U.S. Department of Homeland Security
Washington, DC 20528
202-343-1717, [email protected]
www.dhs.gov/privacy

collected and therefore not retrieved by a unique identifier. However, DHS/USCG-013
MISLE does provide notice of this type of information collection.

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