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Privacy Impact Assessment Form
v 1.21
Status

Form Number

Form Date

Question

Answer

1

OPDIV:

CDC

2

PIA Unique Identifier:

TBD

2a Name:

24 National Disease Data (NDSP)
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.

Initiation
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

Epidemiologist

POC Name

Ryan Maddox

POC Organization OID/NCEZID/DHCPP/PPHO
POC Email

[email protected]

POC Phone

404-639-1170
New
Existing
Yes
No

Sep 30, 2016
Not Applicable

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8c

Briefly explain why security authorization is not
required

N/A

10

Describe in further detail any changes to the system
that have occurred since the last PIA.

N/A

11 Describe the purpose of the system.

The purpose purpose for reporting communicable diseases is
to determine the prevalence of diseases dangerous to public
health. Collecting this data provides the basis for planning and
evaluating effective programs for prevention and control of
infectious diseases. The information submitted on the disease
incidences are needed to identify and study present and
emerging disease problems.

Patient's DOB, Age, First 3 letters of Patient's last name,
Describe the type of information the system will
Patient's initials, Patients Date of Death, State of Death,
collect, maintain (store), or share. (Subsequent
Ethnicity/Race, Patient' s State, Patient's County, Patient's Sex
12
questions will identify if this information is PII and ask and Physician contact info
about the specific data elements.)
This information is pulled from multiple forms.

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

The goal of the system is to collect disease specific surveillance
reports of rare, uncommon or infrequent disease. The data will
be used to determine the prevalence of diseases dangerous to
public health. The data will also be used for planning and
evaluating effective programs for prevention and control of
infectious diseases. Disease incidence is needed to study
present and emerging disease problems.
Yes

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

Indicate the type of PII that the system will collect or
15
maintain.

No
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

Physician Contact Info.

Ethnicity/Race

Sex

First 3 letters of last name

Date of Death

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Employees
Public Citizens
16

Business Partners/Contacts (Federal, state, local agencies)

Indicate the categories of individuals about whom PII
is collected, maintained or shared.

Vendors/Suppliers/Contractors
Patients
Other

17 How many individuals' PII is in the system?

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)

5,000-9,999
The information is used for epidemiological analysis to
coordinate and evaluate nationwide surveillance system of
Creutzfeldt-Jakob Disease, Reye Syndrome, and Kawasaki
Disease.
None

20 Describe the function of the SSN.

N/A

20a Cite the legal authority to use the SSN.

N/A

Public Health Service Act, Section 301, "Research and
Identify legal authorities governing information use Investigation," (42 U.S.C. 241); and Sections 304, 306 and 308(d)
21
and disclosure specific to the system and program.
Reye's Syndrome Reporting Act.

22

Yes

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

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.

Published:
Published:
In Progress

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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.

OMB No. 0920-0009, Expires 04/30/2016
Yes

24 Is the PII shared with other organizations?

No
Within HHS
Other Federal
Agency/Agencies
State or Local
To make the States aware of the case
Agency/Agencies

Identify with whom the PII is shared or disclosed and
24a
for what purpose.

Private Sector
Describe any agreements in place that authorizes the
information sharing or disclosure (e.g. Computer
24b Matching Agreement, Memorandum of
None
Understanding (MOU), or Information Sharing
Agreement (ISA)).
24c

Describe the procedures for accounting for
disclosures

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.

N/A
Not Applicable; At time of sample collection individuals are
notified their information is being sent to the CDC by state
health department staff. Individuals can choose not to write
their address or their full name with the state.
CDC will process the sample regardless of what information is
placed on the form.

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26

Voluntary

Is the submission of PII by individuals voluntary or
mandatory?

Mandatory

Not Applicable: State Health departments collect this data and
Describe the method for individuals to opt-out of the therefore is responsible for handling this issue. Individuals can
collection or use of their PII. If there is no option to
choose not to write their address or their full name.
27
object to the information collection, provide a
reason.
CDC will process the sample regardless of what information is
placed on the form.
Describe the process to notify and obtain consent
from the individuals whose PII is in the system when
major changes occur to the system (e.g., disclosure
28 and/or data uses have changed since the notice at
the time of original collection). Alternatively, describe
why they cannot be notified or have their consent
obtained.
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.

None. The information is received from the state and they are
responsible for handling this issue.

Not applicable to CDC because the data are obtained and
provided to CDC by State Health Agencies. State Health
department's takes the responsibility for accurate data
collecting and making the necessary changes.
Annual Self -Assessment.
Surveillance questions, including those related to PII, are
routinely reviewed to ensure that accurate and relevant
information is collected. System data are regularly analyzed,
interpreted, and shared within the scientific community, which
contributes to system integrity.
Users
Administrators

31

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

Users enter surveillance data, including
PII, into the system, analyze the data,
Administrators grant system access to
users.

Developers
Contractors
Others

Describe the procedures in place to determine which Only those requiring access to the system as part of their job
responsibilities (i.e., users) will be granted access by system
32 system users (administrators, developers,
administrators after giving authorization by Business Steward.
contractors, etc.) may access PII.
These users will have access to surveillance data, including PII.
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.
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.
Describe training system users receive (above and
35 beyond general security and privacy awareness
training).

The system has role base access to limit information
accessibility.

CDC Security Awareness Training

N/A

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Do contracts include Federal Acquisition Regulation
36 and other appropriate clauses ensuring adherence to
privacy provisions and practices?

Yes
No

Describe the process and guidelines in place with
37 regard to the retention and destruction of PII. Cite
specific records retention schedules.

Following the Scientific and Research Project Records
(N1-442-09-001).
Records are retained and disposed of in accordance with the
CDC Records Control Schedule (N1-442-09-001). A copy of
study reports are maintained in agency in accordance with
retention schedules. Source documents for computer are
disposed of when no longer needed by program officials.
Personal identifiers may be deleted from records when no
longer needed in the study as determined by the system
manager, and as provided in the signed consent form, as
appropriate. Disposal methods include erasing computer
tapes, burning or shredding paper materials or transferring
records to the Federal Records Center when no longer needed
for evaluation and analysis. Records are retained for over 20
years; for longer periods if further study is needed.

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

Documents with PII will be secured both physically and
electronically. Physical surveillance forms will be stored in
locked cabinets within employee badge-secured facilities;
electronic data will be saved on an encrypted network share in
a folder restricted to non-users, within password-protected
computer systems.

REVIEWER QUESTIONS: The following section contains Reviewer Questions which are not to be filled out unless the user is an OPDIV
Senior Officer for Privacy.

Reviewer Questions
1

Are the questions on the PIA answered correctly, accurately, and completely?

Answer
Yes
No

Reviewer
Notes
2

Does the PIA appropriately communicate the purpose of PII in the system and is the purpose
justified by appropriate legal authorities?

Yes

Do system owners demonstrate appropriate understanding of the impact of the PII in the
system and provide sufficient oversight to employees and contractors?

Yes

No

Reviewer
Notes
3

No

Reviewer
Notes
4

Does the PIA appropriately describe the PII quality and integrity of the data?

Yes
No

Reviewer
Notes
5

Is this a candidate for PII minimization?

Yes
No

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Reviewer Questions

Answer

Reviewer
Notes
6

Does the PIA accurately identify data retention procedures and records retention schedules?

Yes
No

Reviewer
Notes
7

Are the individuals whose PII is in the system provided appropriate participation?

Yes
No

Reviewer
Notes
8

Does the PIA raise any concerns about the security of the PII?

Yes
No

Reviewer
Notes
9

Is applicability of the Privacy Act captured correctly and is a SORN published or does it need
to be?

Yes
No

Reviewer
Notes
10

Is the PII appropriately limited for use internally and with third parties?

Yes
No

Reviewer
Notes
11

Does the PIA demonstrate compliance with all Web privacy requirements?

Yes
No

Reviewer
Notes
12

Were any changes made to the system because of the completion of this PIA?

Yes
No

Reviewer
Notes

General Comments

OPDIV Senior Official
for Privacy Signature

Beverly E.
Walker -S

Digitally signed by Beverly E. Walker -S
DN: c=US, o=U.S. Government,
ou=HHS, ou=CDC, ou=People,
0.9.2342.19200300.100.1.1=100144034
3, cn=Beverly E. Walker -S
Date: 2016.05.31 16:15:43 -04'00'

HHS Senior
Agency Official
for Privacy

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