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:

I-212

Form Title:

Application for Permission to Reapply for Admission into the
United States After Deportation or Removal

Component:

U.S. Citizenship and
Immigration Services
(USCIS)

Office:

Service Center
Operations (SCOPS)

IF COVERED BY THE PAPERWORK REDUCTION ACT:
Collection Title:
Click here to enter text.
OMB Control
Number:
Collection status:

Name:
Office:
Phone:

1615-0018
Revision

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

June 30, 2017
Click here to enter
a date.

PROJECT OR PROGRAM MANAGER
Angela Lyons
SCOPS
Title:
Adjudications Officer
202.272.1585
Email:
[email protected]
v
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:

Heather Young
Office of Policy and
Strategy

Title:

Project Manager

Phone:

202.272.1556

Email:

[email protected]
ov

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.
The Form I-212, Application for Permission to Reapply for Admission into the United States
After Deportation or Removal (OMB No. 1615-0018) expires March 31, 2017 and is
scheduled to undergo an Information Collection Revision. The form and instructions are
scheduled for non-substantive plain language updates to include Standard Language required
by Office of Management and Budget (OMB). USCIS continues to use the USCIS ELIS
Account Number to verify whether the applicant has an existing USCIS ELIS account.
An alien who is inadmissible under section 212(a)(9)(A) or (C) of the Immigration and
Nationality Act (INA) files Form I-212 to obtain "consent to reapply for admission" that is
required before the alien can lawfully return to the United States. "Consent to reapply" is also
called "permission to reapply."
Relevant Information Technology
USCIS processes completed Form I- 212 in ICMS at the field offices and through CLAIMS 3
at the service centers. The application is stored in the A-file.
Form I-212 will also be processed by the USCIS Electronic Immigration System (USCIS
ELIS).
Changes made to the document since the last adjudication are:
Added:
1) Family Members as a Category of Individuals under 2E
o Family Full Name, Relationship, Date of Birth, Physical Address
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Privacy Office
U.S. Department of Homeland Security
Washington, DC 20528
202-343-1717, [email protected]
www.dhs.gov/privacy

2) Add Cell Phone Number for Interpreter and Form Preparer
Removed:
1) Facsimile from Form Preparer

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.
I-212, Application for Permission to Reapply for Admission Into the United States After
Deportation or Removal
An alien who is inadmissible under section 212(a)(9)(A) or (C) of the Immigration and
Nationality Act (INA) files Form I-212 to obtain "consent to reapply for admission" that is
required before the alien can lawfully return to the United States. "Consent to reapply" is also
called "permission to reapply."

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.

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.)

☒ 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.
☐ 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? 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.
For the Applicant, the I-212 is collects full name, A-number, date and country of birth,
nationality/citizenship, details regarding the applicant’s removal, inadmissibility, departures
and re-entry, alias names and dates of birth, separate physical and mailing address, USCIS
ELIS account number, SSN, DOS Consular Case number, location and date of visa interview,
gender, race, height, weight, eye color, hair color, phone number, cell number and email
address, information about any I-601 being filed (date, receipt, office), and signature.
Family members, family full name, relationship, date of birth, physical address
For Interpreters, the I-212 asks for full name, organization name, mailing address, phone
number, cell phone, and signature.

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

For Preparers, the I-212 asks for full name, organization, mailing address, phone, cell phone,
email address, and signature.
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 (signature)
☐ Other. Please list:
g. List the specific authority to collect SSN or these other SPII elements.
INA 264(f) (8 U.S.C. 1304(f)) provides the Secretary of Homeland Security with the specific
authority to collect SSNs of those applying for immigration benefits.

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 collects the SSN to facilitate and expedite the adjudication of the applicant’s request
for a Form I-212 waiver. The SSN is requested in order to expedite the adjudication of the
waiver application by verifying true identity of the applicant, validating the related
immigration history and ensuring security by assisting to accurately match criminal
information to applicants.
USCIS personnel conduct background security checks on applicants for the purpose of
determining whether the applicant has established eligibility for the benefit requested. Because
the I-212 is typically a non-interview, paper-based adjudication, the SSN is especially useful
and provides significant information to verify an applicant’s identity and his/her claim to
eligibility: providing a critical tool for more accurate and appropriate adjudication
determinations for USCIS and the applicant.

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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.
A Privacy Act Statement is provided on the form.
☐ No.

3) How will DHS store the IC/form responses?
a. How will DHS store
☒ Paper. Please describe.
the original,
Document is stored in A-file
completed
IC/forms?
☐ Electronic. Please describe the IT system that will
store the data from the form. ☐ Scanned forms
(completed forms are scanned into an electronic
repository). Please describe the electronic repository.
Click here to enter text.
b. If electronic, how
does DHS input the
responses into the
IT system?

☒ Manually (data elements manually entered). Please
describe. The information is submitted manually by
employees with Lockbox.
☐ Automatically. Please describe.
Click here to enter text.

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.

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

information
retrieved?

Records retrieved by name, A number, date and country
of Birth and Graphical User Interface (GUI) system.
.☐ By a non-personal identifier. Please describe.

Click here to enter text.
Five years. The record schedule number is N1-85-96-01.

d. What is the records
retention
schedule(s)?
Include the records
schedule number.
The system owner is responsible for ensuring the records
e. How do you ensure
are deleted in accordance with the approved records
that records are
retention schedule.
disposed of or
deleted 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.

Form I-212 applications filed overseas are accessible to Department of State consular officers.
s☐ 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:

Kim Mott

Date submitted to component Privacy
Office:
Date submitted to DHS Privacy Office:

November 22, 2016

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.)

February 6, 2017
☐ Yes. Please include it with this PTA
submission.
☒ No. Please describe why not.
USCIS Office of Privacy developed a Privacy
Act Statement and is seeking program and
OCC approval.

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 I-212, Application for Permission to Reapply for Admission into the United States
After Deportation or Removal (OMB No. 1615-0018) expires March 31, 2017 and is scheduled
to undergo an Information Collection Revision. The form and instructions are scheduled for
non-substantive plain language updates to include Standard Language required by Office of
Management and Budget (OMB). USCIS continues to use the USCIS ELIS Account Number to
verify whether the applicant has an existing USCIS ELIS account.
I-212, Application for Permission to Reapply for Admission Into the United States After
Deportation or Removal
An alien who is inadmissible under section 212(a)(9)(A) or (C) of the Immigration and
Nationality Act (INA) files Form I-212 to obtain "consent to reapply for admission" that is
required before the alien can lawfully return to the United States. "Consent to reapply" is also
called "permission to reapply."
Relevant Information Technology
USCIS processes completed Form I- 212 in ICMS at the field offices and through CLAIMS 3 at
the service centers. The application is stored in the A-file.
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Privacy Office
U.S. Department of Homeland Security
Washington, DC 20528
202-343-1717, [email protected]
www.dhs.gov/privacy

Form I-212 will also be processed by the USCIS Electronic Immigration System (USCIS ELIS).
The Office of Privacy recommends this is a privacy sensitive form and is covered under existing
PIA and SORNs.
PIA





DHS/USCIS/PIA – 016(a) Computer Linked Application Information Management
System (CLAIMS 3) and Associated Systems since it’s processed in CLAIMS 3.
DHS/USCIS/PIA – 056 USCIS Electronic Immigration System (USCIS ELIS). USCIS
ELIS is an electronic case management system that allows USCIS to process certain
immigration benefit requests.
Forthcoming CAP Tracker PIA since this is one of the forms for this system.

SORN
 DHS/USCIS - 007 Benefits Information System, October 19, 2016 (81 FR 72069) which
collects, uses, and maintains the Benefit Information System records to administer
immigrant or nonimmigrant benefit requests.
 DHS/USCIS/ICE/CBP – 001 Alien File, Index, and National File Tracking System of
Records, November 1, 2013 (78 FR 69864) since this is where the application is stored.

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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:

Max Binstock

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

1138293
February 9, 2017
February 9, 2018

Privacy Sensitive IC or
Form:

DESIGNATION
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:

DHS PRIV has not received this ICR/Form.

Date IC/Form Approved Click here to enter a date.
by PRIV:
IC/Form PCTS Number: Click here to enter text.
Privacy Act
New e(3) statement is required.
Statement:
Click here to enter text.
PTA:
New system PTA required.
Click here to enter text.
PIA:
PIA Appendix update required
If covered by existing PIA, please list: DHS/USCIS/PIA-016(a) Computer
Linked Application Information Management System (CLAIMS 3) and
Associated Systems;
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Privacy Office
U.S. Department of Homeland Security
Washington, DC 20528
202-343-1717, [email protected]
www.dhs.gov/privacy

If a PIA update is required, please list: DHS/USCIS/PIA-056 USCIS ELIS;
Forthcoming CAP Tracker PIA
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, November 21,
2013, 78 FR 69864; DHS/USCIS-007 Benefits Information System,
October 19, 2016, 81 FR 72069
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.
USCIS Privacy is submitting this PTA because Form I-212, expires March 31, 2017
and is scheduled to undergo an Information Collection Revision. The form and
instructions are scheduled for non-substantive plain language updates to include
Standard Language required by OMB.
PRIV finds that is a privacy sensitive system and a PIA is required because Form I212 collects PII from members of the public. PRIV agrees with USCIS Privacy
recommendation that the CLAIMS 3 PIA provides coverage. Form I-212 is processed
in CLAIMS 3. PRIV finds that an Appendix update is required to the USCIS ELIS PIA to
include the processing of Form I-212. PRIV also agrees with USCIS Privacy that the
forthcoming CAP Tracker PIA must include discussion of Form I-212. In its current
draft, there are no references to the form.
PRIV finds that a SORN is required because Form I-212 retrieves information by a
unique identifier. PRIV agrees with USCIS Privacy that the A-File SORN and BIS SORN
provide adequate coverage. DHS/USCIS/ICE/CBP-001 covers the paper and
electronic copy A-File and/or Receipt File, supplemental forms, supplemental
evidence, and identity history summaries (formally known as RAP sheets), but does
not include all case processing and decisional data. DHS/USCIS-007 covers USCIS'
collection, use, maintenance, dissemination, and storage of benefit request
information, including case processing and decisional data not included in the A-file.
PRIV finds that a PAS is also required on Form I-212.
This PTA will expire in one year.

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