1625-0042 Privacy Threshold Analysis (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.

Privacy Threshold Analysis – IC/Form

Version number: 04-2016
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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:

CG-4020

Form Title:

4 Hour Advance Notice of Transfer

Component:

U.S. Coast Guard (USCG)

Office:

CG-REG

IF COVERED BY THE PAPERWORK REDUCTION ACT:
Collection Title:
Requirements for Lightering of Oil and Hazardous Material Cargoes,
and Advance Notice of Transfer
June 30, 2019
OMB Control
1625-0042
OMB Expiration
Number:
Date:
Collection status:
Extension
Date of last PTA (if
Click here to enter
applicable):
a date.

Name:
Office:
Phone:

Name:
Office:
Phone:

PROJECT OR PROGRAM MANAGER
Mr. David Du Pont
CG-REG
Title:
Reg Dev Mgr
202-372-1497
Email:
[email protected]
COMPONENT INFORMATION COLLECTION/FORMS CONTACT
Mr. Arthur Requina
CG-612
Title:
Forms Manager
202-475-3651
Email:
[email protected]

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

SPECIFIC IC/Forms PTA QUESTIONS
1. Purpose of the Information Collection or Form
The purpose of the form (CG-4020) is for a waterfront facility and/or vessel to provide
the Coast Guard advance notice of oil or hazardous material transfer operations. The
information enhances the Coast Guard ability to respond to an emergency and minimize
the environmental damage from an oil or hazardous material spill. The information is
also use to monitor certain transfer operations.
Form CG-4020 contains basic business contact information, which may include the name,
address and phone/fax/email of the facility and/or vessel, if owned/operated by an
individual.
The authority for this collection is 33 U.S.C. 1225.

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.

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.

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.
Privacy Threshold Analysis – 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

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? The form contains basic business
contact information, which may include the name, address and phone/fax/email
of the facility and/or vessel, if owned/operated by an individual.
f. Does this form collect Social Security number (SSN) or other element that is
stand-alone Sensitive Personally Identifiable Information (SPII)? No.
☐ 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.
N/A.

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

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.
N/A.
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 PAS is on the form.
☐No.

3. How will DHS store the IC/form responses?
a. How will DHS store
☐Paper. Please describe.
the original,
Click here to enter text.
completed IC/forms?
☐Electronic. Please describe the IT system that will
store the data from the form.
Click here to enter text.
Scanned forms (completed forms are scanned into
an electronic repository). Please describe the
electronic repository.
Forms that the Coast Guard receive are
maintained in Marine Information for Safety and Law
Enforcement (MISLE) database.
b. If electronic, how
does DHS input the
responses into the IT
system?

Manually (data elements manually entered).
Please describe.
A scanned form is uploaded to the facility or
vessel-specific file in MISLE.
☐Automatically. Please describe.
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

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

☐By a unique identifier.2 Please describe. If
information is retrieved by personal identifier, please
submit a Privacy Act Statement with this PTA.
Click here to enter text.
By a non-personal identifier. Please describe.
A search is accomplished using facility or vesselspecific information.
A record is retained for the life of the facility or vessel;
NARA retention schedule number N1-026-05-015.

d. What is the records
retention
schedule(s)? Include
the records schedule
number.
e. How do you ensure
As records are maintained in the MISLE database,
that records are
disposal/deletion is in accordance with the business
disposed of or deleted
rules for the database.
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.

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

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:

A.L. Craig

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

April 22, 2019

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.)

April 24, 2019
x Yes. Please include it with this PTA
submission.
☐No. Please describe why not.
Click here to enter text.

Component Privacy Office Recommendation:.
The 4 Hour Advance Notice of Transfer (CG-4020) is for a waterfront facility and/or vessel to provide the
Coast Guard advance notice of oil or hazardous material transfer operations. The information enhances
the Coast Guard ability to respond to an emergency and minimize the environmental damage from an oil
or hazardous material spill. The information is also use to monitor certain transfer operations.
CG-4020 contains basic business contact information, which may include the name, address and
phone/fax/email of the facility and/or vessel, if owned/operated by an individual.
DHS/USCG/PIA-008 Marine Information for Safety and Law Enforcement (MISLE) and DHS/USCG013 Marine Information for Safety and Law Enforcement (MISLE) provides coverage for this collection.

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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:

Joseph McCaskill

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

1179956
April 30, 2019
April 30, 2022
Riley Dean

DESIGNATION
Privacy Sensitive IC or
Form:

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:

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
Privacy Notice Required
Statement:

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

USCG Privacy should change the Privacy Act Statement to a Privacy
Notice on FORM CG-4020, and ensure the Privacy Notice remains
accurate based on this PTA
PTA:
System PTA Required
Click here to enter text.
PIA:
System covered by existing PIA
If covered by existing PIA, please list: DHS/USCG/PIA-008 Marine
Information for Safety and Law Enforcement (MISLE)
If a PIA update is required, please list: Click here to enter text.
SORN:
SORN Not Required
If covered by existing SORN, please list:
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.
USCG Privacy is submitting this form PTA for CG-4020, which collects PII and information
for a waterfront facility and/or vessel to provide to the Coast Guard advance notice of oil or
hazardous material transfer operations. The information enhances the Coast Guard ability
to respond to an emergency and minimize the environmental damage from an oil or
hazardous material spill. The information is also use to monitor certain transfer
operations. Form CG-4020 contains basic business contact information, which may include
the name, address and phone/fax/email of the facility and/or vessel, if owned/operated by
an individual. The authority for this collection is 33 U.S.C. 1225.
DHS Privacy Office (PRIV) finds this is a privacy sensitive system. The collection of business
contact information for the purpose of USCG response to environmental damage is covered
by DHS/USCG/PIA-008. The retrieval of information is by vessel or facility-specific
information, and no SORN coverage is required; however, DHS/USCG-013 SORN does
provide general notice of this type of information collection. The Privacy Act Statement
should be changed to a Privacy Notice due to information not being retrieved by a unique
identifier. This PTA is valid until April 30, 2022.

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