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Privacy Impact Assessment Form
v 1.47.4
Status Draft

Form Number

F-80142

Form Date

Question

Answer

1

OPDIV:

CDC

2

PIA Unique Identifier:

P-1496061-751658

2a Name:

8/5/2019 7:36:50 AM

STEADI Cost Effectiveness (SCE)
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.

Implementation
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

Behavioral Scientist

POC Name

Gwendolyn Bergen

POC Organization CDC/ONDIEH/NCIPC/DUIP
POC Email

[email protected]

POC Phone

770.488.1394
New
Existing
Yes
No
November 4, 2019
Not Applicable

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11 Describe the purpose of the system.

The purpose of this project is to implement the CDC’s STEADI
(Stopping Elderly Accidents, Deaths, and Injuries) initiative into
outpatient practice in a health system, evaluate the impact on
falls and medically treated falls, and develop a cost
effectiveness for the STEADI initiative. A full implementation of
STEADI will be tested along with two modified
implementations. Data will be collected from providers,
research nurses, clinical nurses, IT staff, practice managers, and
patients to improve the implementation.
The information system will collect, maintain and store
patient's name, email address, phone number, mailing address
and user credentials (Userid and password). The Pin is not
collected or stored. Data will be collected from providers to
improve the implementation and from patients to obtain their
falls record and understand their fall prevention behaviors.
Other data collected include identifying patients risk of falling;
assessments to identify which fall risk factors are present. (e.g.,
medication review, functional ability test, visual acuity,
orthostatic blood pressure, podiatry review, vitamin D intake,
and home hazard evaluation), strategies to reduce fall risk.
(e.g., strength and balance program, manage medications,
occupational therapy, vitamin D supplements, corrective
eyewear).

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 A full implementation of STEADI will be tested along with two
modified implementations. Data will be collected from
about the specific data elements.)
providers to improve the implementation and from patients to
obtain their falls record and understand their fall prevention
behaviors. This will include STEADI implementation and
process questions, practice cost of implementation questions
and feedback from patients.
Data will also be collected from providers, research nurses,
clinical nurses, IT staff, practice managers, and patients to
improve the implementation.
Interviews will be conducted with providers, research nurses,
clinical nurses, IT staff, practice managers, and patients. Data
will be collected in-person using hard-copy questionnaires. All
data collected will be stored temporarily or until contract
expires.

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STEADI Cost Effectiveness (SCE) is a full Moderate information
system whose purpose is to implement the CDC’s STEADI
(Stopping Elderly Accidents, Deaths, and Injuries) initiative into
outpatient practice in a health system, evaluate the impact on
falls and medically treated falls, and develop a cost
effectiveness for the STEADI initiative).
STEADI is a suite of materials intended to help healthcare
providers implement the clinical practice guidelines developed
by the American and British Geriatric Societies for prevention
of falls among older Americans. STEADI includes the following
core elements such as screening to identify patients at
increased risk of falling; assessments to identify which
modifiable fall risk factors are present. (e.g., medication
review, functional ability test, visual acuity, orthostatic blood
pressure, podiatry review, vitamin D intake, and home hazard
evaluation), and intervene using effective strategies to reduce
fall risk. (e.g., strength and balance program, manage
medications, occupational therapy, vitamin D supplements,
corrective eyewear).
Provide an overview of the system and describe the
13 information it will collect, maintain (store), or share,
either permanently or temporarily.

A full implementation of STEADI will be tested along with two
modified implementations. Data will be collected from
providers to improve the implementation and from patients to
obtain their falls record and understand their fall prevention
behaviors. This will include STEADI implementation and
process questions, practice cost of implementation questions
and feedback from patients.
The information system will also collect, maintain and store
patient's name, email address, phone number, mailing address
and user credentials (Userid and password). The Pin is not
collected or stored. Data will be collected from providers to
improve the implementation and from patients to obtain their
falls record and understand their fall prevention behaviors.
Data will also be collected from providers, research nurses,
clinical nurses, IT staff, practice managers, and patients to
improve the implementation.
Interviews will be conducted with providers, research nurses,
clinical nurses, IT staff, practice managers, and patients. Data
will be collected in-person using hardcopy questionnaires. All
data collected will be stored temporarily or until contract
expires.

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
user id and password

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)

500-4,999
PII will be used to contact participants, both initially and for
follow-up.
N/A

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 301, "Research and
and disclosure specific to the system and program.
Investigation" (42 U.S.C. 241).

22

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

Yes
No

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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.

24 Is the PII shared with other organizations?
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?

Describe the method for individuals to opt-out of the
collection or use of their PII. If there is no option to
27
object to the information collection, provide a
reason.
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.

The OMB information collection approval number and
expiration date is pending.
Yes
No
The participants are informed that personal information would
be collected prior to consent to do interview. At the time of
screening all participants, interviewers will include information
about how the data will be used.
Voluntary
Mandatory
The participants can decline to participate in the study
altogether or withdraw their participation at anytime. If they
want to opt-out prior to or after completing the survey, they
can do so by contacting the IT Security Compliance Manager at
(312) 759-2667.

Study personnel will contact participants via email and phone
number on record to notify and obtain consent when major
changes occur to the system.

The participants may report their concerns about any
erroneous PII or any inappropriate attainment, use or
disclosure to [email protected] or call
888-879-6672.

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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.

31

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

NORC admin periodically (every quarter) reviews and
compares the PII contained in the system for the participants
against the database to ensure the data's integrity, availability,
accuracy and relevancy.
Users

NORC users conduct interviews and or
manage the data collection process.

Administrators

NORC Admins have full rights to
maintain and support the overall
system.

Developers
Contractors

In-direct contractors need access to
manage the data collection process.

Others
Describe the procedures in place to determine which The Contractors, Administrators and developers may be
32 system users (administrators, developers,
granted access to the data. Access is based on role-based
contractors, etc.) may access PII.
Access control and the least privilege method as authorized by
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.

The least privilege model will be used to allow those with
access to PII to be able to access the minimum amount of PII
needed to perform their job. All access is granted through
Active Directory. Individual Active Directory groups are
created for each project. Only the project staff that require
access are added to the project group.

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.

All staff are required to take annual training in cybersecurity,
security awareness and privacy training. This training has been
reviewed and is compatible with CDC requirements.

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

All system users are required to receive annual system specific
training on system use, Health Insurance Portability and
Accountability Act (HIPAA), Ethics, and Compliance.

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
Records retention is in accordance with the CDC Records
Control Schedule (N1-442-09-1) and in accordance with
contractual agreement. Record copy of study reports are
maintained in agency from two to three years 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 20 years;
for longer periods if further study is needed.

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Administrative controls include a system security plan,
contingency plan, regular back up of files and storage of
backups off site, role-based security awareness training, least
privilege access enforced through Active Directory groups,
separate user and privileged accounts for administrators,
policies and procedures in place for retention and destruction
of PII, and a corporate incident response team and incident
response plans. During the study, data is secured through the
use of technical, physical, and administrative controls. All data
is stored in a secure data center with limited access. All access
is via electronic card readers. The data center has special
environment controls to monitor for disruption to electrical or
air conditioner failure.
Describe, briefly but with specificity, how the PII will
38 be secured in the system using administrative,
technical, and physical controls.

Technical controls include identification and authentication
using unique user IDs, passwords, and smart cards, use of
firewalls and intrusion detection/prevention systems, virus
scanning software on all computers, and a security information
and event management (SIEM) solution. Servers and
workstations are protected with anti-virus software. Their
configuration follow the Computer Internet Security
configuration and FDCC standard. Security patches are
automated and applied at least monthly depending on the
criticality of the patch. All systems have vulnerability scans
performed monthly.
Physical controls include guards, identification badges, key
cards, and closed circuit TV.Data backups are encrypted and
sent off site in case of disaster at the primary processing
facility.

General Comments

OPDIV Senior Official
for Privacy Signature

Q40a: In accordance with HHS’s “Rescission of Office of the Chief Information Officer/Superseded Policy
for Machine Readable Privacy Policies and Related Guidance Documents” memo. MRPP cannot be
validated due to obsolete technology and the suspension of work on P3P by the Platform for Privacy
Preferences Project workgroup.
signed by Jarell
Jarell Oshodi Digitally
Oshodi -S
Date: 2019.09.12 10:57:17
-S
-04'00'

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