Forms 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:

ICE Form 73-028

Form Title:

ICE Mutual Agreement Between Government and Employers
(IMAGE) Self-Assessment Questionnaire
Immigration and
Office:
Homeland Security
Customs Enforcement
Investigations (HSI)
(ICE)

Component:

IF COVERED BY THE PAPERWORK REDUCTION ACT:
Collection Title:
ICE Mutual Agreement between Government and Employers (IMAGE)
Click here to enter a
OMB Control
1653-0048
OMB Expiration
date.
Number:
Date:
Collection status:
Extension
Date of last PTA (if
April 27, 2017
applicable):

Name:
Office:
Phone:

Name:

PROJECT OR PROGRAM MANAGER
John J. Morris
HSI – Worksite
Title:
Special Agent-Program
Enforcement Unit
Manager
202-732-5409
Email:
[email protected]
COMPONENT INFORMATION COLLECTION/FORMS CONTACT
Scott A. Elmore

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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:

Office of the Chief
Title:
ICE Forms Manager/PRA
Information Officer
Clearance Officer
202-732-2601
Email:
[email protected]
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.
This U.S. Immigration and Customs Enforcement Mutual Agreement between
Government and Employers (IMAGE) forms PTA is being submitted for a three-year
renewal. No personally identifiable information (PII) changes will be made to this form.
The U.S. Immigration and Customs Enforcement IMAGE is the outreach and education
component of the Homeland Security Investigations (HSI) Worksite Enforcement (WSE)
program. IMAGE is designed to build cooperative relationships with the private sector to
enhance compliance with immigration laws and reduce the number of unauthorized
aliens within the United States workforce. Under this program, ICE partners with
employers representing a broad cross-section of industries. An employer initially
completes the IMAGE Self-Assessment Questionnaire so that ICE can evaluate the
employer for inclusion in the IMAGE program. After ICE performs its evaluation and
determines that an employer is suitable to become an IMAGE participant, ICE enters into
a formal written agreement with the employer, and the employer receives assistance
from ICE in the area of immigration worksite enforcement. The formal written
agreement does not contain any PII other than business contact information for the
employer’s point of contact. A paper copy of the agreement is stored in a locked cabinet
and/or room, and an electronic copy is saved on a limited-access shared drive.

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.
8 U.S.C. § 1324

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

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.
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)

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

Provide link:
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 form collects contact information of a POC for the business entity that is applying for
the IMAGE program. This PII includes:
•
•
•
•
•
•

Name;
Job Title;
Address;
Telephone number;
Fax number; and
Email address.

The form also collects information related to the employer, including Federal Employer
Identification Number, Secretary of State Business ID Number, E-Verify Identification
Number, SSNVS User ID Number, and number of employees. In addition, in Section D of
the form, the employer is asked to provide numerous supporting documents as
attachments to the form. However, the only PII in these documents is contact
information for certain human resources personnel.

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

N/A – It is not collected

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 – It is not collected

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. The collection is done with a questionnaire
filled out by the employer, so the employer is
aware of the collection. In addition, the form
includes a Privacy Act Statement that explains why
the information is being collected, how it may be
shared, and whether providing the information is
mandatory or voluntary.
☐ No.

3. How will DHS store the IC/form responses?
a. How will DHS store
☒ Paper. Please describe.
the original,
Paper copies of the form may be stored at ICE
completed IC/forms?
Headquarters and/or a field office in a locked
cabinet and/or room. Access is limited to a subset
of Homeland Security Investigations (HSI)
personnel with a need to know this information as
part of their official responsibilities.
☒ Electronic. Please describe the IT system that will
store the data from the form.
The form may also be received as an Adobe pdf by
email already filled out by the employer. If so, it is
saved on the ICE Critical Infrastructure Shared
Drive at Headquarters. Access is restricted to HQ
Worksite Enforcement Unit personnel.

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

☐ Scanned forms (completed forms are scanned into
an electronic repository). Please describe the
electronic repository.
N/A
b. If electronic, how
does DHS input the
responses into the IT
system?

☒ Manually (data elements manually entered). Please
describe.
The form may be received as an Adobe pdf by
email already filled out by the employer.
☐ Automatically. Please describe.
N/A -it is not done automatically

c. How would a user
☐ By a unique identifier.2 Please describe. If
search the
information is retrieved by personal identifier, please
information
submit a Privacy Act Statement with this PTA.
submitted on the
N/A -It is not retrieved that way
forms, i.e., how is the
☒ By a non-personal identifier. Please describe.
information
The form is retrieved by the name of the employer
retrieved?
d. What is the records
There is no current approved record retention
retention
schedule.
schedule(s)? Include
the records schedule
number.
e. How do you ensure
The records are being maintained permanently until a
that records are
record retention schedule is established.
disposed of or deleted
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.
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

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.

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:

Kevin Mullinix

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

February 10, 2020

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.)

February 24, 2020
☒ 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 ICE Office of Information Governance and Privacy recommends approval of the threeyear renewal of ICE Form 73-028, ICE Mutual Agreement Between Government and
Employers (IMAGE) Self-Assessment Questionnaire. The form is covered by the following
Privacy Impact Assessment (PIA): DHS/ALL/PIA-006 DHS General Contact Lists. Because
this form is not retrieved by personal identifier, SORN coverage is not required.
Nevertheless, the information on this form may be used as necessary and is authorized by
the routine uses published in the DHS/ALL-002 Mailing and Other Lists Systems of Records
(73 FR 71659, November 25, 2008).

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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:

Hannah Burgess

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

Click here to enter text.
March 6, 2020
March 6, 2023

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
Choose an item.
Statement:
Click here to enter text.
PTA:
Choose an item.
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/ALL/PIA-006 DHS General
Contacts List
If a PIA update is required, please list: Click here to enter text.
SORN:
Choose an item.
If covered by existing SORN, please list: Click here to enter text.
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.
ICE is submitting this PTA to discuss ICE Form 73-028, ICE Mutual Agreement Between
Government and Employers (IMAGE) Self-Assessment Questionnaire, which is used by employers
who are partnering with ICE so that ICE can evaluate the employer for inclusion in the IMAGE
program. After ICE performs its evaluation and determines that an employer is suitable to become an
IMAGE participant, ICE enters into a formal written agreement with the employer, and the employer
receives assistance from ICE in the area of immigration worksite enforcement.
The formal written agreement does not contain any PII other than business contact information for
the employer’s point of contact. A paper copy of the agreement is stored in a locked cabinet and/or
room, and an electronic copy is saved on a limited-access shared drive.
PRIV finds that is a privacy sensitive system and a PIA is required because IMAGE Self-Assessment
Questionnaire collects PII from members of the public. PRIV agrees with ICE Privacy that
DHS/ALL/PIA-006 DHS General Contact Lists provides coverage.
A privacy act statement was submitted and approved along with this PTA.
PRIV strongly recommends that ICE establish a records retention schedule for this form.

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