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Privacy Impact Assessment Form
v 1.21
Status

Form Number

920-18FJ

Question
1

OPDIV:

2

PIA Unique Identifier:

2a Name:

Form Date

08/22/18

Answer
CDC

Evaluation of the Chronic Disease Self-Management Program in
General Support System (GSS)
Major Application

3

Minor Application (stand-alone)

The subject of this PIA is which of the following?

Minor Application (child)
Electronic Information Collection
Unknown

3a

Identify the Enterprise Performance Lifecycle Phase
of the system.

Initiation
Yes

3b Is this a FISMA-Reportable system?

4

Does the system include a Website or online
application available to and for the use of the general
public?

5

Identify the operator.

6

Point of Contact (POC):

7

Is this a new or existing system?

8

Does the system have Security Authorization (SA)?

No
Yes
No
Agency
Contractor
POC Title

Islands Coordinator

POC Name

Stacy De Jesus

POC Organization CDC
POC Email

[email protected]

POC Phone

770-488-6393
New
Existing
Yes
No

8b Planned Date of Security Authorization
Not Applicable

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Briefly explain why security authorization is not
8c
required

10

Describe in further detail any changes to the system
that have occurred since the last PIA.

11 Describe the purpose of the system.

Evaluation data will be collected through 2 paper-based forms:
a workshop evaluation form and a questionnaire. Data will
then be entered into Excel with no identifiable information
included.
N/A, this is a new data collection.
CDC will collect information from participants in workshops
aimed at teaching adults with chronic diseases how to manage
those conditions in the US Affiliated Pacific Islands (USAPIs),
which include American Samoa, Guam, the Commonwealth of
the Northern Mariana Islands, the Republic of Palau, the
Republic of the Marshall Islands, and the Federated States of
Micronesia. These jurisdictions began implementing the
workshops using Stanford University's Chronic Disease SelfManagement Program (CDSMP) curriculum in 2016.
Participants will provide their assessment of the workshop and
answer questionnaires to measure changes in their responses
from pre-workshop to post-workshop.
CDC will collect this information to understand how CDSMP is
being implemented in the region, to identify barriers and
facilitators to implementation, document any adaptations to
the curriculum made by the USAPIs, and the effects of the
program on program participants. Collecting these data will
help CDC understand if CDSMP, as implemented in the USAPIs,
has the same effect there as it has in other ethnic groups within
the United States.
Two paper-based data collection instruments will be used. The
first is a CDSMP workshop evaluation form that will assess
program participant satisfaction with CDSMP. A paper
evaluation form will be administered to all participants at the
end of the 6 week workshop. No identifying information will
be collected. Results will be used to assess satisfaction with
the delivery of CDSMP and to identify ways to improve the
delivery of CDSMP.

Describe the type of information the system will
The second instrument is a pre/post test for CDSMP program
collect, maintain (store), or share. (Subsequent
12
questions will identify if this information is PII and ask participants. It will assess chronic disease related symptoms,
self-efficacy and health behaviors before CDSMP and at the
about the specific data elements.)
end of the 6 week workshop. The paper questionnaire will be
administered at the start the program and the same
questionnaire will be administered at the end of the 6 week
workshop to compare information. These questionnaires
include the participant name. The name will be redacted and
replaced with a unique identification number. Questionnaire
items include demographics such as age group, race/ethnicity,
education, language, and marital status.

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Questionnaires will be administered on paper to workshop
participants at the first and last session by the CDSMP
workshop leaders. The paper questionnaires will be
transmitted to CDC. CDC will enter the questionnaire
responses into Excel for analysis. The information transmitted
to, and entered by, CDC will not include any personal
identifiers.

Provide an overview of the system and describe the
13 information it will collect, maintain (store), or share,
either permanently or temporarily.

Names will be collected on the pre/post questionnaires;
however, names will be redacted by the CDSMP workshop
leaders and replaced by unique identifiers on each
questionnaire, prior to sending copies of the questionnaires to
CDC. Survey administrators will keep a log of participant
names and identifiers, separately from the questionnaires. The
unique identifier will be used to match pre/post questionnaires
so that change can be assessed. CDC will not receive names or
the log. The questionnaires will be temporarily stored, for up
to 3 years. They will be destroyed when no longer needed
after analyses are completed.
These data will be analyzed to evaluate the fidelity to the
curriculum as designed by Stanford and any adaptations to
CDSMP made in USAPIs, and to understand if CDSMP, an
evidence-based intervention, has the same effect in the US
Affiliated Pacific Islands as it has in multiple ethnic groups
within the United States. If shown to be successful, CDSMP will
be promoted and offer an evidence based intervention to help
people with chronic disease(s) better manage their conditions
and improve their health. The public health impact will be
improved health for the citizens of the USAPIs suffering from
chronic diseases.

Yes

14 Does the system collect, maintain, use or share PII?

Indicate the type of PII that the system will collect or
15
maintain.

No
Social Security Number

Date of Birth

Name

Photographic Identifiers

Driver's License Number

Biometric Identifiers

Mother's Maiden Name

Vehicle Identifiers

E-Mail Address

Mailing Address

Phone Numbers

Medical Records Number

Medical Notes

Financial Account Info

Certificates

Legal Documents

Education Records

Device Identifiers

Military Status

Employment Status

Foreign Activities

Passport Number

Taxpayer ID
marital status

Other...

Race/ethnicity

Other...

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Employees
Public Citizens
16

Business Partners/Contacts (Federal, state, local agencies)

Indicate the categories of individuals about whom PII
is collected, maintained or shared.

Vendors/Suppliers/Contractors
Patients
Other

17 How many individuals' PII is in the system?

18 For what primary purpose is the PII used?

19

Describe the secondary uses for which the PII will be
used (e.g. testing, training or research)

100-499
Names are collected to match the pre-post questionnaires to
assess chronic disease symptoms and health behaviors before
and after CDSMP. However, the names will be replaced with a
unique identifier for data entry and storage. Therefore, only
unique identifiers will be in the data file.
N/A

20 Describe the function of the SSN.

N/A

20a Cite the legal authority to use the SSN.

N/A

21

Identify legal authorities governing information use
Section 301(a) of the PHS Act, 42 U.S.C. 241(a)
and disclosure specific to the system and program.

22

Are records on the system retrieved by one or more
PII data elements?

Yes
No
Directly from an individual about whom the
information pertains
In-Person
Hard Copy: Mail/Fax
Email
Online
Other
Government Sources

23

Within the OPDIV
Other HHS OPDIV
State/Local/Tribal
Foreign
Other Federal Entities
Other

Identify the sources of PII in the system.

Non-Government Sources
Members of the Public
Commercial Data Broker
Public Media/Internet
Private Sector
Other

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23a

Identify the OMB information collection approval
number and expiration date.

0920-18FJ, new data collection request
Yes

24 Is the PII shared with other organizations?
Describe the process in place to notify individuals
25 that their personal information will be collected. If
no prior notice is given, explain the reason.
26

No
Individuals will provide their own names on the instruments.
Workshop leaders, in the field, will inform participants that
their names will be used to compare the pre-post surveys and
then replaced with unique identifers.
Voluntary

Is the submission of PII by individuals voluntary or
mandatory?

Mandatory

Describe the method for individuals to opt-out of the
collection or use of their PII. If there is no option to
Individuals can choose not to complete the pre-post test; it is
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object to the information collection, provide a
voluntary.
reason.
Describe the process to notify and obtain consent
from the individuals whose PII is in the system when
major changes occur to the system (e.g., disclosure
There is no process. Individuals cannot be notified because
28 and/or data uses have changed since the notice at
CDC does not have contact information for any workshop
the time of original collection). Alternatively, describe participants.
why they cannot be notified or have their consent
obtained.
Describe the process in place to resolve an
individual's concerns when they believe their PII has
29 been inappropriately obtained, used, or disclosed, or
that the PII is inaccurate. If no process exists, explain
why not.

There is no process because CDC has no means of identifying
workshop participants. Potential respondents are notified that
completing the questionnaire is voluntary and that their names
will not be shared beyond their trainer.

Describe the process in place for periodic reviews of
PII contained in the system to ensure the data's
30
integrity, availability, accuracy and relevancy. If no
processes are in place, explain why not.

There is no process for periodic reviews because no PII is stored
electronically.
Users
Administrators

31

Identify who will have access to the PII in the system
and the reason why they require access.

Developers
Contractors
Others

Only the individuals who assign
unique identifiers will see the log with

Describe the procedures in place to determine which
According to the protocol for the project, only the trainers who
32 system users (administrators, developers,
administer the questionnaires will see the PII.
contractors, etc.) may access PII.
Describe the methods in place to allow those with
33 access to PII to only access the minimum amount of
information necessary to perform their job.

The CDC project officer ensures that only those who administer
the survey will see the PII.

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Identify training and awareness provided to
personnel (system owners, managers, operators,
contractors and/or program managers) using the
34
system to make them aware of their responsibilities
for protecting the information being collected and
maintained.

Only 2 CDC staff will access the system in order to analyze the
data and write a report. The Islands Coordinator will ensure
that the 2 staff are aware of their responsibilities for protecting
information. CDC staff complete Security and Privacy Training
on an annual basis.

Describe training system users receive (above and
35 beyond general security and privacy awareness
training).

N/A

Do contracts include Federal Acquisition Regulation
36 and other appropriate clauses ensuring adherence to
privacy provisions and practices?

Yes
No

Describe the process and guidelines in place with
37 regard to the retention and destruction of PII. Cite
specific records retention schedules.

These data will be maintained in accordance with Records
Control Schedule DAA-GRS-2-13-0002-0008: temporarily stored
for up to 3 years and then destroyed.

Describe, briefly but with specificity, how the PII will
38 be secured in the system using administrative,
technical, and physical controls.

No PII will exist on any electronic system. PII (names) will be
written on paper questionnaires and then redacted before
copies of the questionnaires are sent to CDC. The paper
questionnaires will be secured in locked file cabinets only
accessible by the survey leader. Physical copies of surveys will
be destroyed when no longer needed.

REVIEWER QUESTIONS: The following section contains Reviewer Questions which are not to be filled out unless the user is an OPDIV
Senior Officer for Privacy.

Reviewer Questions
1

Are the questions on the PIA answered correctly, accurately, and completely?

Answer
Yes
No

Reviewer
Notes
2

Does the PIA appropriately communicate the purpose of PII in the system and is the purpose
justified by appropriate legal authorities?

Yes

Do system owners demonstrate appropriate understanding of the impact of the PII in the
system and provide sufficient oversight to employees and contractors?

Yes

No

Reviewer
Notes
3

No

Reviewer
Notes
4

Does the PIA appropriately describe the PII quality and integrity of the data?

Yes
No

Reviewer
Notes
5

Is this a candidate for PII minimization?

Yes
No

Reviewer
Notes

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Reviewer Questions
6

Answer

Does the PIA accurately identify data retention procedures and records retention schedules?

Yes
No

Reviewer
Notes
7

Are the individuals whose PII is in the system provided appropriate participation?

Yes
No

Reviewer
Notes
8

Does the PIA raise any concerns about the security of the PII?

Yes
No

Reviewer
Notes
9

Is applicability of the Privacy Act captured correctly and is a SORN published or does it need
to be?

Yes
No

Reviewer
Notes
10

Is the PII appropriately limited for use internally and with third parties?

Yes
No

Reviewer
Notes
11

Does the PIA demonstrate compliance with all Web privacy requirements?

Yes
No

Reviewer
Notes
12

Were any changes made to the system because of the completion of this PIA?

Yes
No

Reviewer
Notes

General Comments

OPDIV Senior Official
for Privacy Signature

Beverly E.
Walker -S

Digitally signed by
Beverly E. Walker -S
Date: 2018.08.22
18:33:25 -04'00'

HHS Senior
Agency Official
for Privacy

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