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.
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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:

G-1041 and G-1041A

Form Title:

Genealogy Index Search Request (G-1041) and Genealogy
Records Request (G-1041A).

Component:

U.S. Citizenship and
Immigration Services
(USCIS)

Office:

Genealogy Program

IF COVERED BY THE PAPERWORK REDUCTION ACT:
Collection Title:
Form G-1041, Genealogy Index Search Request
Form G-1041A, Genealogy Records Request
OMB Control
1615-0096
Number:
Collection status: Extension
Name:
Office:
Phone:

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

May 31, 2019
June 3, 2015

PROJECT OR PROGRAM MANAGER
Donna R. Ring
Genealogy Program
Title:
Section Chief
816-350-5572
Email:
[email protected]

COMPONENT INFORMATION COLLECTION/FORMS CONTACT

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

Name:
Office:

Phone:

Evadne J. Hagigal
Click here to enter text.

Title:

Management and Program
Analyst
(202) 272-0993
Email:
[email protected].
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.
2019 Extension
USCIS is submitting this PTA to extend the use of Form G-1041 and G-1041A under the
Paperwork Reduction Act. There has not been any change to the form. The current
form approval is set to expire on May 31, 2019.
Form G-1041, Genealogy Index Search Request and Form G-1041A, Genealogy
Records Request
The USCIS Genealogy Program provides access to historical immigration and
naturalization records of deceased immigrants to family historians and other
researchers through two fee-based services:

1. Index Search: Form G-1041, Genealogy Index Search Request is used to request a
search of USCIS historical databases. Request for searches of these databases
are used to determine whether any records pertaining to a subject exists, and, if
such records exist, to collect record citations (i.e., USCIS file numbers). The fee
for an index search is $65.00
2. Record Copy Request: Form G-1041A, Genealogy Records Request is used to
obtain copies of USCIS historical records. Researchers with valid record
citations, gained through the index search (Form G-1041) or through
independent research, may request microfilm and/or paper-based copies of
genealogy records. The fee for a record copy request is $65.00 per record
requested.

This form can be filled out and submitted to USCIS by researchers seeking records of
their ancestry for genealogical or family history purposes; historians or social

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

scientists seeking historical records of persons that can be identified by name, date of
birth and place of birth; or by the researcher involved by their last name.

Relevant Information Technology
The MiDAS (Microfilm Digitization Application System)
Genealogy Case Management Tracking (CMT) Subsystem is used to track the customer
requests, their status, the responsive records, and the response provided. If submitted
thru the lockbox, the physical form is scanned into the CMT system then the paper
copy is shredded and not retained.
The Genealogy Program utilizes MiDAS to search for historical files on the record
subject as a result of a 1041. As it pertains to G-1041A, Genealogy Program uses RAILS
to confirm file location and CIS (Central Index System) and ARCIS (Archives and
Records Information System) to request files out of retirement. The historical files are
stored at the Federal Records Center (FRC) and File Control Offices (FCOs).

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.

8 U.S. Code 1356
2. Describe the IC/Form
a. Does this form collect any
Personally Identifiable
Information” (PII 1)?

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
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

c. Who will complete and
submit this form? (Check
all that apply.)

☐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.

d. How do individuals
complete the form? Check
all that apply.

☒ Other individual/entity/organization that is
NOT the record subject. Please describe.
Subjects in the files being requested are deceased.
Anyone can request their information. USCIS
reviews and applies FOIA Privacy exemptions to
3rd parties information that we do not have proof
of death or consent for.

☒ Paper.
☒ Electronic. (ex: fillable PDF)
☐ Online web form. (available and submitted via
the internet)
Provide link: https://genealogy.uscis.dhs.gov/

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.
Form G-1041

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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 about the requester:
• Full name
• Address
• Contact information
• Signature

Information about the subject of the request:
• Full name
• Aliases
• Date of birth
• Country of birth
• Proof of death (if immigrant is less than 100 years of age)
• Date of entry into the United States (Optional)
• Address of residence in the United States (optional)

Form G-1041A
Information about the requester:
• Full name
• Address
• Contact information

Information about the subject of the request:
• Full name
• Aliases
• Date of birth
• Country of birth
• Type of file requested
• File number associated with the request
• A-number
• Visa file
• C-File
• Naturalization certificate number
• AR-2 files
• Date of entry into the United States

In addition, USCIS requires a filing fee to be submitted for both forms. Payment for the
forms can be accomplished electronically through pay.gov, or a cashier's check or
money order. Personal checks are not accepted and are returned to the requester.
USCIS destroys the original paper-based payment but maintains a copy of it for
payment confirmation purposes.

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

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
X Other. Please list following file
numbers: Visa, Registry Number, AR-2
and A file as well as C file. USCIS does
not keep or track SSN.

g. List the specific authority to collect SSN or these other SPII elements.
8 U.S. Code 1356

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.
USCIS needs the identifying information to locate information on the subject of record for
Index Searches or for Record Requests in our Index Searching database MiDAS.
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.
Click here to enter text.

☐No.

3. How will DHS store the IC/form responses?
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Privacy Office
U.S. Department of Homeland Security
Washington, DC 20528
202-343-1717, [email protected]
www.dhs.gov/privacy

a. How will DHS store
the original,
completed IC/forms?

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

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

☐Paper. Please describe.

Click here to enter text.
☒ Electronic. Please describe the IT system that will
store the data from the form.
When the request is submitted on line,
CMT/MiDAS as well as FIPS – Genealogy
Processing system and FOIA record processing
system.
☒ Scanned forms (completed forms are scanned into
an electronic repository). Please describe the
electronic repository.
We scan the paper request into the case entered
into CMT/MiDAS system when submitted on paper
then the paper is shredded.

☒ Manually (data elements manually entered). Please
describe.
For paper requests mailed to the lockbox, we
manually enter the information into CMT to create
a case and keep a copy of the request with the case
and shred the paper copy.
☒ Automatically. Please describe.
When a requestor submits the request on line, a
case is automatically created and they enter the
information into the form lines.
☒ By a unique identifier. 2 Please describe. If
information is retrieved by personal identifier, please
submit a Privacy Act Statement with this PTA.
The requests are searched by last name (requester
and subject of the request) or case number
created for the specific request.
☒ By a non-personal identifier. Please describe.

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

d. What is the records
retention
schedule(s)? Include
the records schedule
number.

The non-personal identifier will be the
case/control number created for each request.
Information contained in the DISR module of MiDAS is
retained and disposed of in accordance with the schedule
approved by the National Archives and Records
Administration (“NARA”) the week of March 13, 2006
(N1-566-06).

e. How do you ensure
We follow the records retention schedule and work
that records are
with the product owner of CMT/MiDAS, Lynda
disposed of or deleted
Spencer.
in accordance with
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

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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:

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.)

Maisonobe G. Fokwa Kengne
December 21, 2018
January 28, 2019

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

The USCIS Office of Privacy recommends to designate Form G-1041/1041A privacy
sensitive with coverage under the following compliance documentations:

PIA:
DHS/USCIS-017(a) Microfilm Digitization Application System (MiDAS), which covers the
processing of information in MiDAS.

SORN:
DHS/USCIS/ICE/CBP-001 Alien File, Index, and National File Tracking System of Records,
which covers the collection and use of information maintained in A-files.

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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:

Jamie Huang

PCTS Workflow Number:
Date approved by DHS Privacy Office:
PTA Expiration Date

1173842
January 30, 2019
January 30, 2022

DESIGNATION

Privacy Sensitive IC or
Form:
Determination:

Yes If “no” PTA adjudication is complete.
☐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.
DHS IC/Forms Review:

☐Other. Click here to enter text.
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:
Existing Privacy Notice is sufficient
PTA:
No system PTA required.
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

System covered by existing PIA
If covered by existing PIA, please list: DHS/USCIS-017(a) Microfilm
Digitization Application System (MiDAS)
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/USCIS/ICE/CBP-001 Alien
File, Index, and National File Tracking System of Records, September 18,
2017, 82 FR 43556
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.
PIA:

USCIS is submitting this PTA to extend the use of Forms G-1041 and G-1041A under the
Paperwork Reduction Act. The current forms are set to expire on May 31, 2019. Form G1041 is the Genealogy Index Search Request, and Form G-1041A is the Genealogy Records
Request document. The USCIS Genealogy Program provides access to historical
immigration and naturalization records of deceased immigrants to family historians and
other researchers.

The DHS Privacy Office finds that is a privacy sensitive form and a PIA is required because
both forms collect PII from members of the public regarding historical immigrant records
for genealogical and research purposes. PRIV agrees with USCIS Privacy that the
DHS/USCIS-017(a) Microfilm Digitization Application System (MiDAS) covers members of
the public requesting immigration records for research purposes.

PRIV finds that a SORN is required for the forms because information is retrieved by a
unique identifier in MiDAS. PRIV agrees with USCIS Privacy that DHS/USCIS/ICE/CBP-001
covers the collection and use of information maintained in A-files.
PRIV also finds that a PAS is required to be included with this form informing individuals
how their information will be used and shared, noting that information listed in Form G1041 and G-1041A is retrievable by the requestor’s name and other identifiers.

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