Privacy Threshold Analysis

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:
Form Title:

Component:

I-690
Application for Waiver of Grounds of Inadmissibility Under
Sections 245A or 210 of the Immigration and Nationality Act
U.S. Citizenship and
Immigration Services
(USCIS)

Office:

Field Operations
Directorate

IF COVERED BY THE PAPERWORK REDUCTION ACT:
Collection Title:
Application for Waiver of Grounds of Inadmissibility Under
Sections 245A or 210 of the Immigration and Nationality Act
December 31, 2018
OMB Control
1615-0032
OMB Expiration
Number:
Date:
Collection status:
Revision
Date of last PTA (if
May 20, 2016
applicable):

Name:
Office:
Phone:

PROJECT OR PROGRAM MANAGER
Frederick J. Dimichele
Field Operations
Title:
Adjudications Officer
Directorate
[email protected]
202-766-0744
Email:
ov

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

Name:
Office:
Phone:

Kerstin A. Jager
Office of Policy and
Strategy
202-213-4211

Title:

Management Program
Analyst
Email:
[email protected]
v
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.
Respondents that would provide information through Form I-690 to seek a waiver of one
or more inadmissibility grounds under Section 212 of the INA, include applicants who
are otherwise inadmissible or who are deemed inadmissible to the United States as they:
1. Have been diagnosed with Tuberculosis;
2. Are requesting waiving vaccination requirements under INA 212(a)(1)(A)(ii)
due to a religious or moral objection;
3. Have a physical or mental disorder associated with harmful behavior;
4. Have a substance abuse condition or drug addiction; or
5. Are subject to another inadmissibility ground not excepted by statute.
USCIS uses the information provided through Form I-690 to grant waivers to
individuals who would have otherwise not been admissible the United States. Based
upon the instructions provided for each occurrence, a respondent can gather and submit
the required documentation to USCIS for consideration of an inadmissibility waiver
based on one of the four instances mentioned immediately above. Upon receiving the
request, USCIS will review all of the information provided to determine if the specific
requirements under Section 212 of the INA have been met. USCIS will also use the
information provided to determine that the issue that requires a waiver will be properly
addressed by the respondent after admission to the United States to ensure, when
applicable, that the condition that required the waiver does not change to the point
where the waiver would no longer be deemed valid.

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

USCIS is updating Form I-690 to clarify reasons for the application and provide more
detailed instructions. For example, USCIS is standardizing the Biometric Services
appointment language on forms that already request the collection of biometrics, and
forms that will now require biometric collection. The Form I-690 already included the
Biometric service appointment language, but is now being revised.
Form I-690 Supplement 1, Applicants with a Class A Tuberculosis Condition:
Applicants with a Class A Tuberculosis Condition are required to submit a completed I690 Supplement 1 with the waiver application. Supplement 1 is completed by the
applicant, physician or medical facility that will provide the required treatment, and a
state health department official. The Supplement 1 is not new, however, this was not
previously accounted for in the last PTA.
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.
An individual seeking to adjust status to that of U.S. Legal Permanent Resident under
Sections 210 and 245A of the Immigration and Nationality Act (INA) may request a
waiver of a ground of inadmissibility, including of one or more of the medical grounds
stated under Section 212(a) of the INA, by completing and submitting a Form I-690,
Application for Waiver of Grounds of Inadmissibility (Form I-690). The information
provided through this form allows U.S. Citizenship and Immigration Services (USCIS) to
determine an applicant’s eligibility for a waiver of one or more grounds of
inadmissibility.

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.

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

☐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.
Supplement A is completed by a physician or
medical facility, and a state health department
official.

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)
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.
Information about the applicant, attorney, applicant’s relatives, interpreter, and preparer
is collected.
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Privacy Office
U.S. Department of Homeland Security
Washington, DC 20528
202-343-1717, [email protected]
www.dhs.gov/privacy

Information collected about the applicant includes:
• A-Number (if one)
• USCIS Online Account Number (if any)
• U.S. Social Security Number (if any)
• Relating receipt number (if any)
• Full Name
• Aliases
• City/town/village and country of birth
• Date of birth
• Physical Address
• Mailing Address
• Biographic information- including ethnicity, race, height, weight, eye color and hair
color.
Information collected about the attorney includes:
• Attorney State Bar Number (if applicable)
• Attorney or Accredited Representative USCIS Online Account Number (if any)
Information collected about the applicant’s relatives includes:
• A- Number (if any)
• Full Name
• Address
• Date of Birth
• Relationship
• Immigration Status
Information collected about the interpreter includes:
• Full Name
• Name of Business or Organization(if any)
• Mailing Address
• Daytime Phone Number
• Mobile Phone Number (if any)
• E-mail Address(if any)
Information collected about the preparer includes:
• Full Name
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Privacy Office
U.S. Department of Homeland Security
Washington, DC 20528
202-343-1717, [email protected]
www.dhs.gov/privacy

• Name of Business or Organization(if any)
• Mailing Address
• Daytime Phone Number
• Mobile Phone Number (if any)
• E-mail Address(if any)
Supplement 1:
Information collected about the physician includes:
 Full Name
 Name of Business or Organization(if any)
 Address
 Daytime Phone Number
 Signature
Endorsement or State Health Department Official:
 Official name of Department
 Name of official providing endorsement
 Title of official providing endorsement
 Signature
 Address
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.
Sections 103 and 264(f) of the Immigration and Nationality Act
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Privacy Office
U.S. Department of Homeland Security
Washington, DC 20528
202-343-1717, [email protected]
www.dhs.gov/privacy

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.
The social security number (SSN) may be used to verify the applicant’s identity. The SSN
can also be used when investigating potential fraud or criminal issues in various records
and systems, as it is a unique identifier, just as are fingerprints. The A-Number may be
used to identify the applicant and examine the applicant’s immigration history. Records
associated with the applicant through his or her A-Number may inform the decision on
the waiver application.
i. Are individuals
☒ Yes. Please describe how notice is provided.
provided notice at the
USCIS includes a Privacy Notice in the form
time of collection by
instructions.
DHS (Does the records
☐No.
subject have notice of
the collection or is
form filled out by
third party)?

3. How will DHS store the IC/form responses?
a. How will DHS store
☒ Paper. Please describe.
the original,
Alien File
completed IC/forms?
☒ Electronic. Please describe the IT system that will
store the data from the form.
Data from the form are stored in the Computer
Linked Application Information Management System
(CLAIMS) 3.
☐Scanned forms (completed forms are scanned into
an electronic repository). Please describe the
electronic repository.
Click here to enter text.
b. If electronic, how
does DHS input the

☒ Manually (data elements manually entered). Please
describe.

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

responses into the IT
system?

Upon receipt, data are manually keyed into
CLAIMS 3. Upon adjudication, the decision is
recorded electronically to update the record in
CLAIMS.
☐Automatically. Please describe.
Click here to enter text.

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
Any of the unique identifiers listed in question 2e.
forms, i.e., how is the
☐By a non-personal identifier. Please describe.
information
Click here to enter text.
retrieved?
d. What is the records
The form will be retained permanently within the Aretention
File.
schedule(s)? Include
the records schedule
number.
e. How do you ensure
that records are
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. It may be shared
with Immigration and Customs Enforcement (ICE) or Customs and Border Protection
(CBP), as appropriate..
☒ Yes, information is shared external to DHS with other federal agencies, state/local
partners, international partners, or non-governmental entities. 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

There are certain occasions when copies of the form are shared with HHS CDC
strictly for medical recommendation/consultation.
This sharing is permitted in accordance with Routine Use P of the BIS SORN under
draft:
P. Consistent with the requirements of the Immigration and Nationality Act, to the
Department of Health and Human Services (HHS), the Centers for Disease Control
and Prevention (CDC), or to any State or local health authorities, to:
1. Provide proper medical oversight of DHS-designated civil surgeons who
perform medical examinations of both arriving foreign nationals and of those
requesting status as a lawful permanent resident; and
2. To ensure that all health issues potentially affecting public health and safety in
the United States are being or have been, adequately addressed.
☐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:

Catherine Shorten

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

July 2, 2018

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.)

August 7, 2018
☒ 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 Form I-690 is used by a person who needs a waiver of inadmissibility in order to be
granted a benefit.
Since the form is processed in CLAIMS 3 and retained in the A-File, we recommend
coverage under the following compliance documents:
• DHS/USCIS/PIA-016(a) CLAIMS 3 and Associated Systems
• DHS/USCIS-007 BIS SORN
• DHS/USCIS-001 A-File SORN
USCIS Office of Privacy also recommends adding the Immigration Biometric and
Background Check SORN as coverage. Although the form itself does not cover the collection
of biometrics, the form requires individuals to schedule a biometrics collection
appointment at an Application Support Center. Moving forward, USCIS plans to add this
SORN as coverage for all forms that require biometric collection.

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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

1167395
August 24, 2018
August 24, 2021

DESIGNATION
Privacy Sensitive IC or
Form:

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

PIA:

System covered by existing PIA
If covered by existing PIA, please list: DHS/USCIS/PIA-016(a) CLAIMS 3 and
Associated Systems

SORN:

If a PIA update is required, please list: Click here to enter text.
System covered by existing SORN
If covered by existing SORN, please list: DHS/USCIS/ICE/CBP-001 – Alien
File, Index, and National File Tracking System of Records, September 18, 2017, 82
FR 43556;
DHS/USCIS-007 - Benefits Information System October 19, 2016 81 FR 72069;
DHS/USCIS-018 Immigration Biometric and Background Check (IBBC) System of
Records, July 31, 2018, 83 FR 36950

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.
USCIS is submitting this PTA to discuss Form I-690, Application for Waiver of Grounds of
Inadmissibility Under Sections 245A or 210 of the Immigration and Nationality Act. The
form is used by individuals who are otherwise inadmissible or who are deemed
inadmissible due to certain conditions to seek a waiver of one or more inadmissibility
grounds under Section 212 of the INA. USCIS uses the information provided through Form
I-690 to grant waivers to individuals who would have otherwise not been admissible the
United States.
USCIS is updating Form I-690 to clarify reasons for the application and provide more
detailed instructions. Additionally, applicants with a Class A Tuberculosis Condition are
required to submit a completed I-690 Supplement 1 with the waiver application.
Supplement 1 is completed by the applicant, physician or medical facility that will provide
the required treatment, and a state health department official. The Supplement 1 is not
new, however, this was not previously accounted for in the last PTA.
The form collects an array of PII and SPII about the applicant, family members, and any
attorney, preparer, interpreter, or physician.
The DHS Privacy Office agrees that this is a privacy sensitive form, requiring PIA coverage.
Coverage is provided by DHS/USCIS/PIA-016(a) CLAIMS 3 and Associated Systems, which
discusses information collected from individuals who are seeking immigration benefits.
SORN coverage is also required as information is retrieved by personal identifier. Coverage
is provided by DHS/USCIS-001 A-File, which covers information contained in the an
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Privacy Office
U.S. Department of Homeland Security
Washington, DC 20528
202-343-1717, [email protected]
www.dhs.gov/privacy

individual’s Alien File, and DHS/USCIS-007 Benefits Information System, which covers
information collected from applicants, interpreters, preparers, physicians, and sponsors as
part of the immigration benefit request process. Although this form does not collect
biometric information, some applicants may be required to schedule a biometric collection
appointment as part of the application process; in that situation, the information would be
covered by DHS/USCIS-018 Immigration Biometric and Background Check.

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