Privacy Impact Assessment Form

Save

Privacy Impact Assessment Form
v 1.47.4
Status Draft

Form Number

F-28722

Form Date

Question

Answer

1

OPDIV:

CDC

2

PIA Unique Identifier:

P-9322259-886705

2a Name:

5/11/2016 8:16:25 AM

Water Fluoridation Reporting System (WFRS)
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.

Operations and Maintenance
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

ISSO

POC Name

Cindy Allen

POC Organization NCCDPHP
POC Email

[email protected]

POC Phone

770-488-5388
New
Existing
Yes
No
May 18, 2016
Not Applicable

Page 1 of 2

Save

9

Indicate the following reason(s) for updating this PIA.
Choose from the following options.

PIA Validation (PIA
Refresh/Annual Review)
Anonymous to NonAnonymous
New Public Access
Internal Flow or Collection

Significant System
Management Change
Alteration in Character of
Data
New Interagency Uses
Conversion

Commercial Sources

10

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

none
This system will monitor the impact of fluoridation on health
outcomes and the progress toward the Healthy People 2020
fluoridation goal. It will also generate national surveillance
reports for optimally fluoridated drinking water.

11 Describe the purpose of the system.

The following information is being collected in the system:
Utility name, address, population served, fluoridation status,
Describe the type of information the system will
natural fluoride concentrations; counties served; communities
collect, maintain (store), or share. (Subsequent
12
questions will identify if this information is PII and ask served; system type and which systems buy or sell water to
other systems; results of daily testing and laboratory split
about the specific data elements.)
sample results; and dates of facility inspections with operator
training dates.

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

The Water Fluoridation Reporting System (WFRS) is a data
management tool developed in partnership with the
Association of State and Territorial Dental Directors (ASTDD).
WFRS assists states in managing the quality of their water
fluoridation programs and administering the state water
fluoridation. Users can generate reports and use the
information to improve the quality of fluoridation in their
jurisdiction.
The following information is maintained: utility name and
address, population served, fluoridation status, natural fluoride
concentrations, counties and communities served, system
type, and which systems buy or sell water to other systems;
results of daily testing; laboratory split sample results; dates of
facility inspections; and dates of operator training.

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

Yes
No

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=10014403
43, cn=Beverly E. Walker -S
Date: 2016.05.11 12:36:13 -04'00'

Page 2 of 2