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Privacy Impact Assessment Form
v 1.21
Status

Form Number

Form Date

Question

Answer

1

OPDIV:

CDC

2

PIA Unique Identifier:

0920-1099

2a Name:

Capacity Building Assistance Program: Assessment and Quality C
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

Behavioral Scientist

POC Name

Miriam E. Phields

POC Organization NCHHSTP/DHAP/CBB
POC Email

[email protected]

POC Phone

404-639-4957
New
Existing
Yes
No

8b Planned Date of Security Authorization
Not Applicable

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8c

Briefly explain why security authorization is not
required

Not applicable.

10

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

Not applicable.

11 Describe the purpose of the system.

The purpose of the three systems involved are to collect,
maintain, and share data with Centers for Disease Control and
Prevention (CDC) and it's contractors as part of program
monitoring and evaluation of the Division of HIV/AIDS
Prevention (DHAP) capacity building assistance (CBA) program.

Describe the type of information the system will
collect, maintain (store), or share. (Subsequent
12
questions will identify if this information is PII and ask
about the specific data elements.)

The system will collect, maintain, and store contact
information, demographic data, training follow-up data,
technical assistance (TA) follow-up data from the recipients of
TA and training, names, work mailing addresses, work phone
numbers, work email addresses, and organization names.
This information collection will use a quantitative collection
approach, utilizing web-based instruments. The mode will vary
based on the CBA type (i.e., training vs. TA). CBA service
recipients will complete the health professional application for
training (HPAT) before any CBA services are delivered. The
HPAT collects information from TA and training participants on
their (1) occupations, professions, and functional roles; (2)
principal employment settings; (3) location of their work
settings; and (4) programmatic and population foci of their
work.

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

At 90 days after a training event, training recipients are invited
to complete the training follow-up survey. The survey consists
of 44 quantitative questions designed to elicit information
from CBA consumers about their satisfaction with training and
trainers, changes in capacity building outcomes (e.g., changes
in knowledge, skills, self-efficacy as a result of training, etc.),
barriers to implementation, and additional CBA needs.
At 45 days after a TA event, TA recipients are invited to
complete the TA follow-up survey. The survey consists of 41
quantitative questions designed to elicit information from CBA
consumers about their satisfaction with theTA its provider,
changes in capacity building outcomes (e.g., changes in
knowledge, skills, self-efficacy as a result of the TA, etc.),
barriers and facilitators to implementation, and preferences for
methods of TA delivery (e.g., phone, email, in-person, etc.).
Confidentiality of data is based on protocols in place to protect
collected CBA-related data. Data will be stored and managed
based on current CDC requirements and standards. CBArelated data will always be treated in a secure manner and will
be disclosed in an aggregate form, unless otherwise compelled
by law. Data is de-identified for analysis purposes.

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

Yes
No

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

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

Organization name

Work mailing address

Work e-mail address

Work phone number

Other...

Employees
Public Citizens
16

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

Business Partners/Contacts (Federal, state, local agencies)
Vendors/Suppliers/Contractors
Patients
Other

17 How many individuals' PII is in the system?

5,000-9,999

18 For what primary purpose is the PII used?

These identifiable HPAT data are primarily needed to complete
registration, and to conduct training and technical assistance.

Describe the secondary uses for which the PII will be
19
used (e.g. testing, training or research)

Secondary uses for PII are to schedule telephone follow-up
with respondents who do not complete the online surveys
within two weeks and to conduct training and technical
assistance.

20 Describe the function of the SSN.

Not applicable.

20a Cite the legal authority to use the SSN.

Not applicable.

Public Health Service Act, Section 301, "Research and
Identify legal authorities governing information use Investigation," (42 U.S.C. 241); and Sections 304, 306 and 308(d)
21
which discuss authority to maintain data and provide
and disclosure specific to the system and program.
assurances of confidentiality for health research and related
activities (42 U.S.C. 242 b, k, and m(d)).
22

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

Yes
No

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Published:
Identify the number and title of the Privacy Act
System of Records Notice (SORN) that is being used
22a
to cover the system or identify if a SORN is being
developed.

Privacy Act System Notice 09-20-0161 Records of

Published:
Published:
In Progress
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
23a

Identify the OMB information collection approval
number and expiration date.

0920-1099
Yes

24 Is the PII shared with other organizations?

No
Within HHS

Identify with whom the PII is shared or disclosed and
24a
for what purpose.

Other Federal
Agency/Agencies
State or Local
Purpose
Agency/Agencies
Private Sector

Describe any agreements in place that authorizes the
information sharing or disclosure (e.g. Computer
24b Matching Agreement, Memorandum of
Understanding (MOU), or Information Sharing
Agreement (ISA)).
24c

Describe the procedures for accounting for
disclosures

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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

Participants are informed that "The requested information is
used only to process your training registration."
Voluntary

Is the submission of PII by individuals voluntary or
mandatory?

Mandatory

Describe the method for individuals to opt-out of the
There is no opt-out option for those registering for a training
collection or use of their PII. If there is no option to
27
course or technical assistance delivery as this information is
object to the information collection, provide a
needed for planning and coordination purposes.
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
28 and/or data uses have changed since the notice at
the time of original collection). Alternatively, describe
why they cannot be notified or have their consent
obtained.

There are no major changes expected for this information
collection, however, individuals can be contacted via phone or
email by local study staff to notify them of any major changes
to the system.

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.

Study participants will be instructed to contact an individual in
the Office of Responsible Research Practices at each local site if
they have any questions about their rights as a participant or
concerns that their PII may have been inappropriately
obtained, used, or disclosed. Contact information will be
included in the study consent form.

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.

Records are routinely reviewed to ensure accuracy for the
purposes of planning and coordination of training and
technical assistance. Records will be retained and destroyed in
accordance with the applicable CDC Records Control Schedule
as mandated by OCISO.
Users
Administrators

31

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

Developers
Contractors

Evaluation contractors use limited PII
to schedule telephone follow-up with

Others
The CDC study team has defined that roles and responsibilities
to access PII be limited to study investigators, namely, coDescribe the procedures in place to determine which principal investigators, the Program Director, and the Program
Manager) to include access to recruitment/retention, survey,
32 system users (administrators, developers,
and interview data.
contractors, etc.) may access PII.
The study data manager has a defined role that will only have
access to survey and interview data.

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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.

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.

Describe training system users receive (above and
35 beyond general security and privacy awareness
training).
Do contracts include Federal Acquisition Regulation
36 and other appropriate clauses ensuring adherence to
privacy provisions and practices?
Describe the process and guidelines in place with
37 regard to the retention and destruction of PII. Cite
specific records retention schedules.

Access to sensitive Personally Identifiable Information (PII) will
be restricted to individuals trained in human subject
protections who are listed on the Institutional Review Board
(IRB) protocol. All PII is collected for a specific and identifiable
purpose with access restricted to specific job tasks and
individuals who perform those tasks. Access to PII in study data
collected for the purposes of analysis is limited to the study
investigators and data manager.
CDC personnel are required to complete the annual OCISO
Security Awareness Training to make them aware of their
responsibilities for protecting the information being collected
and maintained.
Local study staff will undergo data security and confidentiality
training annually and will sign a confidentiality statement
before access to study data is authorized. All local study staff
will be knowledgeable about local data security policy and
procedures and researchers will ensure that the written data
security policy is easily accessible.
Details of training is under the auspices of each local site.
Yes
No
CDC uses the CDC Records Control Schedule for determining
retention and destruction of PII, specifically, section 04-4-40
Surveillance Report of STD Activity, which prescribes that
records be retained and destroyed when no longer needed for
administrative or research purposes or when 30 years old,
whichever comes first.
Administrative: Access to study data remains limited.
Assessment data is not accessed based on PII. Business PII in
limited cases are accessed to contact potential respondents to
complete our training and TA follow-up interviews. Public
access to de-identified study data and aggregated results are
possible in accordance with the data use agreement set by the
center.

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

Technical: The data are stored and managed based on CDC
requirements and standards which includes processes for
handling security incidents and the event monitoring and
incident response. All administrative controls are validated
through a Certification and Authorization (C&A) process as
conducted prior to moving any software application into
production.
Physical: All systems are securely controlled in a new state-ofthe-art data center, which has limited access to badged
personnel.

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Reviewer Questions

Answer

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
6

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

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Reviewer Questions

Answer

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

Jarell
Oshodi -S

Digitally signed by Jarell
HHS Senior
Oshodi -S
Agency Official
Date: 2018.12.10
for Privacy
14:29:00 -05'00'

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