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Privacy Impact Assessment Form
v 1.47.4
Status Draft

Form Number

F-54853

Form Date

Question

Answer

1

OPDIV:

CDC

2

PIA Unique Identifier:

P-1624291-644648

2a Name:

11/29/2018 1:34:16 PM

Maternal Mortality Review Information Application (MMRIA)
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.

Development
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)?

8b Planned Date of Security Authorization

No
Yes
No
Agency
Contractor
POC Title

Maternal Health Team Lead

POC Name

David Goodman

POC Organization CDC/NCCDPHP/DRH
POC Email

[email protected]

POC Phone

770.488.6553
New
Existing
Yes
No
April 2, 2019
Not Applicable

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11 Describe the purpose of the system.

MMRIA provides a repository for the medical and social
information needed for maternal mortality review committee
(MMRC) case review and standardizes data that can be used for
surveillance, monitoring, and research of maternal mortality.
MMRIA provides a common language that helps MMRCs to
collaborate in case review and analyses. MMRIA is a multi-user
data entry system designed to flow like a case review. MMRIA’s
abstraction forms and tools help MMRC members to
understand the story of a woman’s life and the events leading
to her death. Devised to accommodate the scope of work and
processes of MMRCs, the system supports abstraction and
captures committee decisions. MMRIA provides access to semiautomated case narrative templates from which committee
members can print easy-to-read case narrative details. Lastly
MMRIA captures socio-spatial information, through geocoding
of addresses, to expand case discussions and analyses.
MMRIA captures medical and social information on female U.S.
residents who die during pregnancy or within one year of the
end of pregnancy. The sources of the data includes:
death certificate
birth certificate for the index pregnancy if applicable
autopsy reports
prenatal care records
hospitalization records
medical transport records,
informant interviews
maternal mortality review committee deliberations
other medical office records.

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 Each record may contain up to 1000 data elements. A full list of
all data elements collected is available at http://
about the specific data elements.)
demo.mmria.org/data-dictionary/.
The types of PII collected are: name, mother’s maiden name,
email address, medical notes, certificates, military status, date
of birth, mailing address, medical records number, and
employment status.
Users authenticate to the system with a user id and password
which are stored until access is removed by the system
administrator. User credentials are reviewed annually. CDC
Secure Access Management System (SAMS) provides user
authentication and is covered by a separate PIA.

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The system provides a repository for collection of medical and
social information surrounding an individual maternal death.
The types of PII collected are: name, mother’s maiden name,
email address, medical notes, certificates, military status, date
of birth, mailing address, medical records number, and
employment status. The data is used to facilitate review by
state or jurisdiction-based maternal mortality review
committees (MMRCs). It captures MMRC findings and also
provides a cumulative record of standardized indicators
common to most maternal deaths that can be used for
surveillance, monitoring and evidence-informed responses to
maternal mortality.

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

In order to comprehensively review each case of maternal
death, MMRCs must capture detailed medical and social
information on each woman who dies during pregnancy or
within one year of the end of pregnancy in their jurisdiction.
Nurse abstractors glean this information by accessing medical
records and social service records, death certificates, birth
certificates where applicable, and autopsy reports. They then
manually enter relevant case details into MMRIA. The system
provides a semi-automated case narrative that abstractors
then print and provide to committee members to discuss
during MMRC meetings, which occur monthly or quarterly.
During or shortly after meetings, abstractors enter the
committee deliberations including findings on preventability,
contributing factors, and recommendations for action.
The data provided by MMRIA is essential to achieving CDC's
Division of Reproductive Health's goal of improving pregnancy
health and care, and increasing the number of countries and
U.S. states that use effective surveillance systems to monitor
and review maternal deaths. The system supports CDC's role
in detecting and responding to new and emerging health
threats, in tackling the biggest health problems causing death
and disability for Americans, and in bringing new knowledge
to individual health care and community health to save lives.
Users authenticate to the system with a user id and password
are stored until access is removed by the system administrator.
User credentials are reviewed annually. CDC Secure Access
Management System (SAMS) provides user authentication and
is covered by a separate PIA.

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

Yes
No

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15

Indicate the type of PII that the system will collect or
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

Employees
Public Citizens
Business Partners/Contacts (Federal, state, local agencies)
Vendors/Suppliers/Contractors
Indicate the categories of individuals about whom PII
16
is collected, maintained or shared.

Patients
Deceased women who resided in U.S. jurisdictions at
the time of death and who died during pregnancy or
Other within one year of the end of pregnancy; date of birth
is also collected for infants born of the index
pregnancy of the deceased woman

17 How many individuals' PII is in the system?

500-4,999
The PII is used for process management. The abstractors need
to be able to identify individual records in order to enter data
accurately and write a de-identified case narrative that is then
presented to maternal mortality review committee members.

18 For what primary purpose is the PII used?

19

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

Abstractors remove all identifiers before presenting a case to
the committee. The committee members use the de-identified
case narrative to identify contributing factors to the woman's
death and make recommendations for systems-level
improvement.
Though abstractors remove all identifiers before presenting a
case to the committee, military status and employment status
may be included in the case narrative presented to committee
members in order to inform committee deliberations. These
pieces of information are used to identify contributing factors
to the woman's death and to make recommendations.

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20 Describe the function of the SSN.

N/A

20a Cite the legal authority to use the SSN.

N/A

21

Identify legal authorities governing information use
Public Health Service Act, section 306(h) (42 U.S.C. 242k.)
and disclosure specific to the system and program.

22

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

Yes
No
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.

09-20-0166 Vital Statistics for Births, Deaths,
Fetal Deaths, Marriages and Divorces Occurring
in the United States During Each Year

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.

24 Is the PII shared with other organizations?

N/A
Yes
No

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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

Is the submission of PII by individuals voluntary or
mandatory?

Maternal mortality data: No prior notice given because
individuals are deceased. Authority to collect records on
maternal deaths is established at the state or city level.
User data: Notification of collection of users' PII for user
authentication is conducted through SAMS, which is covered
through a separate PIA.
Voluntary
Mandatory

Maternal mortality data: No method exists because individuals
Describe the method for individuals to opt-out of the are deceased.
collection or use of their PII. If there is no option to
27
User data: Notification of collection of users' PII for user
object to the information collection, provide a
authentication is conducted through SAMS, which is covered
reason.
through a separate PIA. Email address is a requirement of
system usage.
Maternal mortality data: No method exists because individuals
are deceased. The majority of PII captured in the system
Describe the process to notify and obtain consent
relates to the deceased women. The birth certificate numbers
from the individuals whose PII is in the system when and dates of birth for infants born of the deceased woman's
major changes occur to the system (e.g., disclosure
index pregnancy are captured when applicable, but state- and
28 and/or data uses have changed since the notice at
city-level authority to conduct maternal mortality review
the time of original collection). Alternatively, describe precludes the need to notify or obtain consent from these
why they cannot be notified or have their consent
infants.
obtained.
User data: Users will be notified via email if major changes
occur.
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.

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.

Maternal mortality data: No process exists because individuals
are deceased.
User data: Users can contact their CDC point of contact to
resolve concerns when they believe their PII has
been inappropriately obtained, used, or disclosed, or
that the PII is inaccurate.
Maternal mortality data: CDC does not have a process in place
for periodic reviews of PII. CDC does not have access to the
data. Each state and city is responsible for conducting periodic
reviews of data integrity, availability, accuracy, and relevancy.
User data: User credentials are reviewed annually by CDC and
state/city points of contact. CDC Secure Access Management
System (SAMS) provides user authentication and is covered by
a separate PIA.

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Users

Identify who will have access to the PII in the system
31
and the reason why they require access.

a limited set of users assigned
"abstractor" user role. PII is necessary
for process management and for
abstractors to produce a de-identified

Administrators
Developers
Contractors
Others

Access is only granted by the CDC/CDC Foundation staffers to
the User Administrators at the state or city level (Jurisdiction
Describe the procedures in place to determine which Administrator). The Jurisdiction administrator would identify
32 system users (administrators, developers,
and assign abstractor access to the individual or select
contractors, etc.) may access PII.
individuals in each state who are responsible for reviewing the
medical and social records and abstracting that information
into the system.
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.

Role based access controls are in place to ensure the concept
of "Least Privilege" model is implemented and only those who
need access will have access. Based on the CDC/CDC
Foundation staffers and Jurisdiction Administrator, Abstractors
may only view records within their state or city.

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.

Training and awareness on best practices regarding PII
collection and confidentiality is provided to personnel at both
the state and city level and by the project team at CDC's
Division of Reproductive Health. The project team provides
this training during initial onboarding of new user jurisdictions
and at annual trainings.

Describe training system users receive (above and
35 beyond general security and privacy awareness
training).

CDC Division of Reproductive Health staff provide a MMRIA
User Manual, annual abstractor and data analysis trainings, and
onsite visits to states and cities before, during, and after
MMRIA adoption.

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.

Yes
No
MMRIA data is owned by the state or jurisdiction entering the
data, not CDC. CDC considers the MMRIA data as intermediary
records (GRS 5.2). The records, include the PII, will be destroyed
when no longer needed for business use.

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Administrative Controls:
Access to PII follows a least privilege model. Access is limited
to those authorized and needing to use the data to perform
job related duties.

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

Technical Controls:
Access to PII follows a least privilege model. Secure logins will
be used to prevent unauthorized access. Multi factor
authentication is required for all users. Storage will utilize FIPScompliant encryption.
Physical Controls:
Physical measures, policies, and procedures are in place to
protect information, buildings, and equipment from
unauthorized intrusions, environmental hazards, and natural
hazards. Server room remains locked at all times with access
limited to individual authorized IT staff with proper security
privileges.

General Comments

OPDIV Senior Official
for Privacy Signature

signed by Jarell
Jarell Oshodi Digitally
Oshodi -S
Date: 2019.03.26 15:14:38
-S
-04'00'

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