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:

Form I-192

Form Title:
Component:

Application for Advance Permission to Enter as a Nonimmigrant
U.S. Citizenship and
Office:
Service Center
Immigration Services
Operations (SCOPS)
(USCIS)

IF COVERED BY THE PAPERWORK REDUCTION ACT:
Collection Title:
Form I-192, Application for Advance Permission to Enter as a
Nonimmigrant
OMB Control
1615-0017
OMB Expiration
June 30, 2018
Number:
Date:
Collection status:
Choose an item.
Date of last PTA (if
April 7, 2015
applicable):
Name:
Office:

Phone:
Name:

PROJECT OR PROGRAM MANAGER
Scott Whelan
Service Center Operations
Title:
Adjudication Officer
HQ
(202) 272-0940
Email:
[email protected]
v

COMPONENT INFORMATION COLLECTION/FORMS CONTACT
Kerstin A. Jager

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

Office:

Phone:

Regulatory Coordination
Division
202-213-4211

Title:

Email:

Adjudication Officer

[email protected]
v
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.
Form Update
Form I-192, Application for Advance Permission to Enter as a Nonimmigrant will expire on
October 31, 2017. USCIS is submitting the Form I-192 PTA because the form is expiring
and will be extended with updates to include data elements previously collected on Form
G-325A that are being added to Form I-192. These data elements are listed below:
•
•
•
•
•
•
•
•

Other names used by the applicant, including alias, maiden name, and nicknames
Gender
5 years of employment history
Mother’s name; date of birth; city or town and country of birth; current city of
residence; current country of residence
Father’s name; date of birth; city or town and country of birth; current city of
residence; current country of residence
Marital status
Information about current spouse; Full Name; A-Number (if any); Date of Birth;
Place of Birth; Place of Marriage
Information about prior marriages; Full Name; Date of Birth; Date of Marriage;
Place of Marriage ; Date Marriage Legally Ended; Place Where Marriage Legally
Ended

Form I-192, Application for Advance Permission to Enter as a Nonimmigrant
USCIS uses this form to address inadmissibility of individuals seeking T (Victims of
Severe Forms of Trafficking in Persons) and U (Victims of Criminal Activity) status under
8 CFR 212.16, 8 CFR 212.17, and 8 CFR 214.14, to apply for permission to enter the

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

United States. The form determines whether the individual should be admitted to the
United States temporarily despite the inadmissibility. For T and U applicants, if the
waiver is approved, this will allow the T or U to enter the US, or, if the T or U applicant is
already in the US, allows the applicant to stay in the US and receive T or U nonimmigrant
status.
Additionally, U.S. Customs and Border Protection (CBP) uses this form to grant
temporary permission under INA section 212(d)(3)(A)(ii) and 8 CFR 212.4 to certain
inadmissible nonimmigrants who are not required to obtain a visa or are already in
possession of the appropriate documents but who wish to enter the United States
through a U.S. Port-of-Entry (POE).

Relevant Information Technology
Data from Form I-192 is stored in CLAIMS 3. Form I-192 applications are submitted to
the USCIS Vermont Service Center (VSC) and Nebraska Service Center (NSC) and are
receipted and adjudicated in CLAIMS 3.

For those seeking entry into the United States as nonimmigrants with CBP at the Port-ofEntry (POE), the applicant files the Form I-192 with CBP. The CBP Admissibility Review
Office uses the Automated Targeting System - Targeting Framework (ATS-TF) to process
this form.
The physical form and supplemental evidence is stored in the A-file.

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.
The authority to collect information in this form is set forth in the Immigration and Nationality
Act, 8 U.S.C. §§ 1103, 1184, 1255, and in the implementing regulations found in volume 8 of
the Code of Federal Regulations (CFR).

2. Describe the 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

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.)

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

d. How do individuals
complete the form? 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.

☒ 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.

☒ Paper.
☒ Electronic. (ex: fillable PDF)
☐ Online web form. (available and submitted via
the internet)
Provide link:

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

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.
The following information is collected from the applicant on Form I-192:
• Full name
• Alien Number (A-Number) (if any)
• USCIS Online Account number (if any)
• Date of Birth
• Place of Birth
• Citizenship or Nationality
• Physical Address including zip code and country
• Addresses where resided during the past 5 years
• Desired Port-of-Entry
• Mode of transportation to the United States
• Date of planned entry into the United States
• Approximate length of stay
• Purpose of stay in the United States
• Reason for inadmissibility
• Date and location of Previous application for advance permission to enter the United
States
• Reason for the request (including inadmissibility), for T and U nonimmigrant seekers,
including whether he/she has previously been in the United States
• Whether the applicant has previously sought an immigration benefit with the United
States
Government
• Whether the applicant has ever been refused admission into the United States; and
• Whether the applicant has ever been arrested, fined, convicted or otherwise engaged
in any criminal activity (including impaired driving)
• Applicant’s Statement, Declaration, Certification, and Signature
• Daytime Telephone Number
• Mobile Telephone Number
• Email Address
• Ethnicity
• Race
• Height
• Weight
• Eye Color

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

•
•
•
•
•
•
•
•
•

Hair Color
Other names used by the applicant, including alias, maiden name, and nicknames
Gender
5 Years of Employment History
Mother’s name; date of birth; city or town and country of birth; current city of
residence; current country of residence
Father’s name; date of birth; city or town and country of birth; current city of
residence; current country of residence
Marital status
Information about current spouse; Full Name; A-Number (if any); Date of Birth; Place
of Birth; Place of Marriage
Information about prior marriages; Full Name; Date of Birth; Date of Marriage; Place
of Marriage ; Date Marriage Legally Ended; Place Where Marriage Legally Ended

The following information is collected from the interpreter:
• Full Name
• Business or Organization Name
• Mailing Address
• Daytime Telephone Number
• Mobile Telephone Number
• Email Address
• Certification and Declaration
• Language Fluency
• Signature
• Date of Signature

The following information is collected from the preparer (if any) on Form I-192:
• Mailing Address
• Daytime Telephone Number
• Mobile Telephone Number
• Email Address (if any)
• Accreditation Statement
• Declaration and Certification
• Signature
• Date of 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

The following information is collected from an attorney or accredited
representative:
• Volag Number
• Attorney State Bar Number
• USCIS Online Account Number (if any)
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
☐ Other. Please list:
g. List the specific authority to collect SSN or these other SPII elements.
8 U.S.C. §§ 1103

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.
The information collected within the form I-192 application is used to assist the DHS in
enforcing the immigration laws of the United States by providing timely and accurate
information about persons who are subject to those laws.
i.

Are individuals
provided notice at the
time of collection by
DHS (Does the records
subject have notice of

Privacy Threshold Analysis – IC/Form

☒ Yes. Please describe how notice is provided.
The form may be completed by the petitioner or by
a third party preparer (attorney, representative,
preparer, etc.). The instructions state what
information is required to complete the 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

the collection or is
form filled out by
third party)?

There is a Privacy Act Statement in the form
instructions.

☐ No.

3. How will DHS store the IC/form responses?
a. How will DHS store
☒ Paper. Please describe.
the original,
All Forms I-192 will be stored and kept as part of the
completed IC/forms?
applicant’s A-file.

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

☒ Electronic. Please describe the IT system that will
store the data from the form.
The information is stored in CLAIMS 3 and ATS
☐ Scanned forms (completed forms are scanned into
an electronic repository). Please describe the
electronic repository.
Click here to enter text.

☒ Manually (data elements manually entered). Please
describe.
Data elements are entered manually by USCIS
contractors and USCIS adjudication officers who
adjudicate the petitions and applications.
☐ Automatically. Please describe.
Click here to enter text.

☒ 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?

A user may search by the A-number, receipt number
for the individual petition, or by name and date of
birth.
☐ By a non-personal identifier. Please describe.
Click here to enter text.
Form I-192: DAA-0566-2017-0008
A-File: N1-566-08-11
CLAIMS3: DAA-0566-2016-0009

d. What is the records
retention
schedule(s)? Include
the records schedule
number.
e. How do you ensure
I-192 covered by DAA-0566-2017-0008 which is
that records are
currently pending at NARA. All Forms I-192, approved
disposed of or deleted
and denied applications are stored in the Alien file
in accordance with
and retained in accordance with the A-File retention
the retention
schedule.
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.
For those seeking entry into the United States as nonimmigrants with CBP at the POE,
the applicant files the Form I-192 with CBP. CBP uses ATS-TF to process this form.
☐ 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.

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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:

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.)

Nina Robinson
May 16, 2017
June 16, 2017
☒ Yes. Please include it with this PTA
submission.
☐ No. Please describe why not.
Click here to enter text.

Component Privacy Office Recommendation:
Please include recommendation below, including what existing privacy compliance
documentation is available or new privacy compliance documentation is needed.
The USCIS Office of Privacy recommendation is to designate Form I-192 as a privacy
sensitive form with coverage under the following:
PIAs
USCIS
• DHS/USCIS/PIA – 016 Computer Linked Application Information Management
Systems (CLAIMS) and Associated System, which covers the storage of electronic
forms in CLAIMS 3
CBP
• DHS/CBP/PIA-006(b) Automated Targeting System (ATS) Update, which covers the
use of ATS by the ARO.
SORNS
• DHS/USCIS/CBP/ICE-001 Alien File, Index, and National File Tracking System of
Records, which covers the collection, use, and storage of the Form I-192 and
supplemental documents 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

USCIS
• DHS/USCIS-007 Benefits Information System, which covers the collection, use, and
storage of data elements USCIS collects from applicants, preparers, interpreters, and
attorney or accredited representative
CBP
•

DHS/CBP-006 – Automated Targeting System, which covers the collection and use
of information to determine admissibility for applicants

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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

1145402
June 27, 2017
June 27, 2020

DESIGNATION

Privacy Sensitive IC or
Form:

Yes If “no” PTA adjudication is complete.

DHS IC/Forms Review:

DHS PRIV has not received this ICR/Form.

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.

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:
A new Privacy Notice needs to be provided with the updated Form.
PTA:
New system PTA required.
Click here to enter text.
PIA:
System covered by existing PIA
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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 covered by existing PIA, please list: DHS/USCIS/PIA-016 Computer
Linked Application Information Management Systems (CLAIMS) and
Associated System; DHS/CBP/PIA-006 Automated Targeting System
(ATS)
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, November 21,
2013, 78 FR 69864; DHS/USCIS-007 Benefits Information System,
October 19, 2016, 81 FR 72069; DHS/CBP-006 Automated Targeting
System, May 22, 2012, 77 FR 30297
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 on behalf of USCIS and CBP because Form I-192
is expiring and will be extended with updates to include data elements previously
collected on Form G-325A that are being added to Form I-192. USCIS uses this form
to address inadmissibility of individuals seeking T (Victims of Severe Forms of
Trafficking in Persons) and U (Victims of Criminal Activity) status under 8 CFR
212.16, 8 CFR 212.17, and 8 CFR 214.14, to apply for permission to enter the United
States.
Additionally, CBP uses this form to grant temporary permission under INA section
212(d)(3)(A)(ii) and 8 CFR 212.4 to certain inadmissible nonimmigrants who are
not required to obtain a visa or are already in possession of the appropriate
documents but who wish to enter the United States through a U.S. Port-of-Entry
(POE).
PRIV finds that is a privacy sensitive system and a PIA is required because Form I192 collects PII from members of the public including non-US persons. PRIV agrees
with USCIS Privacy that CLAIMS 3 PIA and ATS PIA provide coverage.
DHS/USCIS/PIA-016 covers the storage of electronic forms in CLAIMS 3.
DHS/CBP/PIA-006(b) covers the use of ATS by the ARO.
PRIV finds that a SORN is required because the Form I-192 retrieves information by
a unique identifier. SORN coverage is provided by the A-File SORN, BIS SORN, and
ATS SORN. DHS/USCIS/ICE/CBP-001 covers the collection, use, and storage of the
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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-192 and supplemental documents in the A-File. DHS/USCIS-007 covers the
collection, use, and storage of data elements USCIS collects from applicants,
preparers, interpreters, and attorney or accredited representative. DHS/CBP-006
covers the collection and use of information to determine admissibility for
applicants.
PRIV finds that a Privacy Notice is required because Form I-192 collects PII from
non-US persons that are stored in a system of record. A new Privacy Notice needs to
be provided with the updated Form.

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