1625-0010 CG-4917 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

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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 4917

Form Title:

Defect/Noncompliance Report

Component:

U.S. Coast Guard (USCG)

Office:

CG-BSX-23

IF COVERED BY THE PAPERWORK REDUCTION ACT:
U.S. Coast Guard safety standards and regulations under the authority of 46
Collection Title:
OMB Control
Number:
Collection status:

U.S.C. Chapter 43
1625-0010
Extension

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

April 30, 2019
N/A

PROJECT OR PROGRAM MANAGER
Name:
Office:
Phone:

Mr. Kerry L. Freese

Title:
Email:

CG-BSX-23
202-372-1072

Tech. Writer / Editor
[email protected]

COMPONENT INFORMATION COLLECTION/FORMS CONTACT
Name:
Office:
Phone:

Mr. Anthony Smith

Title:
Email:

CG-462
202-475-3532

Privacy Threshold Analysis – IC/Form

PRA Coordinator
[email protected]

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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
According to 46 U.S.C. 4310(d) and (e) and 33 CFR 179.13(a)(2) the manufacturer shall provide the
Commandant of the Coast Guard with an initial report consisting of certain information about the
defect notification and recall campaign being conducted. Upon receipt of information from a
manufacturer indicating the initiation of a recall, the Recreational Boating Product Assurance Branch
assigns a recall campaign number, and sends the manufacturer a CG-4917 form for supplying the
information. The CG-4917 form describes:
(1) the manufacturer's reason for conducting defect notification,
(2) the units affected by the defect or failure to comply,
(3) the degree of danger to the public with continued use of the affected product,
(4) the extent of the problem, and
(5) what corrective action the manufacturer plans to take.
The authorities for this collection are 46 U.S.C. 4310; 46 CFR 160.076); 46 U.S.C. 4310(d) and (e) and
33 CFR 179.13(a)(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).

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

☐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.
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?
Business name, business address, business point of contact, business phone number – if
required, component manufacturer’s business name and address.

f. Does this form collect Social Security number (SSN) or other element that is
stand-alone 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:

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

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.

☐ No.

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.
All forms are stored on the Coast Guard server which
holds the Recreational Boating Production Assurance
Branch (CG-BSX-23) digital folder.

☒ Scanned forms (completed forms are scanned into
an electronic repository). Please describe the
electronic repository.
Paper forms that are received are scanned and stored on
the Coast Guard server which holds the CG-BSX-23
digital folder.

b. If electronic, how
does DHS input the
responses into the IT
system?

☒ Manually (data elements manually entered). Please
describe.
The forms are manually stored in a folder on a USCG
server.

☐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.
Click here to enter text.
☒ By a non-personal identifier.
Each campaign is identified by a campaign number issued
upon initiation of a recall campaign i.e., XXX 16R5721S.
Information is retrieved by the campaign number.
These forms are retained for life and are kept for case
management and historic purposes. N1-026-05-005.

d. What is the records
retention
schedule(s)? Include
the records schedule
number.
Forms are not disposed or deleted, they are maintained as historic
e. How do you ensure
files. Files are transferred to Federal Records Center after 3 years
that records are
and to the National Archives and Records Administration when 20
disposed of or deleted years old.
in accordance with
the retention
schedule?
f. Is any of this information shared outside of the original program/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 describe.
Click here to enter text.
☒ No. Information on this form is not shared outside of the collecting office.

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

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:

June 19, 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.)

August 30, 2018

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

Component Privacy Office Recommendation:
According to 46 U.S.C. 4310(d) and (e) and 33 CFR 179.13(a)(2) the manufacturer shall provide the
Commandant of the Coast Guard with an initial report consisting of certain information about the defect
notification and recall campaign being conducted. The CG-4917 form describes: (1) the manufacturer's
reason for conducting defect notification, (2) the units affected by the defect or failure to comply, (3) the
degree of danger to the public with continued use of the affected product, (4) the extent of the problem,
and (5) what corrective action the manufacturer plans to take.
The form collects the following information: business name, business address, business point of contact,
business phone number – if required, component manufacturer’s business name and address.
DHS/USCG/PIA-008 Marine Information for Safety and Law Enforcement (MISLE) and DHS/USCG013 Marine Information for Safety and Law Enforcement (MISLE) provide coverage for this 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 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 31, 2018
August 31, 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 not required.
Statement:
Because information is not retrieved by personal identifier, a Privacy Act
Statement nor SORN coverage are required.
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-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 Defect/Noncompliance Report, Form CG
4917, which is associated with the U.S. Coast Guard safety standards and regulations
under the authority of 46 U.S.C. 43 and OMB Control Number 1625-0010. The
Recreational Boating Product Assurance Branch (BSX 23) in the Office of Boating
Safety develops and enforces compliance with Coast Guard safety standards and
regulations. Compliance enforcement includes monitoring defect notification and
recall campaigns which boat and engine manufacturers conduct for failures to
comply with applicable Coast Guard safety standards or regulations, and for defects
which in the words of the Federal statutes, "create a substantial risk of personal
injury to the public."
The manufacturer provides USCG with an initial report about the defect notification
and recall campaign being conducted. Upon receipt of information from a
manufacturer indicating the initiation of a recall, BSX 23 assigns a recall campaign
number, and sends the manufacturer a CG 4917 form for supplying the information.
The CG 4917 form describes:
(1) the manufacturer's reason for conducting defect notification,
(2) the units affected by the defect or failure to comply,
(3) the degree of danger to the public with continued use of the affected product,
(4) the extent of the problem, and
(5) what corrective action the manufacturer plans to take.
The form is then completed by the manufacturer. The form is then submitted to
USCG. All forms are stored digitally by BSX 23.
The DHS Privacy Office finds that this form is privacy-sensitive, requiring PIA
coverage.
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Privacy Office
U.S. Department of Homeland Security
Washington, DC 20528
202-343-1717, [email protected]
www.dhs.gov/privacy

PIA coverage 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 collected and therefore not retrieved by a
unique identifier. However, DHS/USCG-013 MISLE does provide notice of this type of
information collection. Additionally, a Privacy Act Statement is not required.

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