Pta

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

Privacy Threshold Analysis
Version number: 06-2020
Page 1 of 60

PRIVACY THRESHOLD ANALYSIS (PTA)

This form will be used to determine whether a Privacy Impact Assessment (PIA), System of Records Notice
(SORN), or other privacy compliance documentation is required under the E-Government Act of 2002, the
Homeland Security Act of 2002, the Privacy Act of 1974, or DHS policy.
Please complete this form and send it to your Component Privacy Office. If you are unsure of your
Component Privacy Office contact information, please visit https://www.dhs.gov/privacy-office-contacts.
If you do not have a Component Privacy Office, please send the PTA to the DHS Privacy Office:
Senior Director, Privacy Compliance
DHS Privacy Office
U.S. Department of Homeland Security
Washington, DC 20528
202-343-1717

[email protected]

Your Component Privacy Office will submit the PTA on behalf of your office. Upon receipt from your
Component Privacy Office, the DHS Privacy Office will review this form. If a PIA, SORN, or other privacy
compliance documentation is required, your Component Privacy Office, in consultation with the DHS
Privacy Office, will send you a copy of the template to complete and return.
For

more

information

about

the

DHS

Privacy

compliance

process,

please

see

https://www.dhs.gov/compliance. A copy of the template is available on DHS Connect at
http://dhsconnect.dhs.gov/org/offices/priv/Pages/Privacy-Compliance.aspx or directly from the DHS
Privacy Office via email: [email protected] or phone: 202-343-1717.

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

Privacy Threshold Analysis
Version number: 06-2020
Page 2 of 60

PRIVACY THRESHOLD ANALYSIS (PTA)
SUMMARY INFORMATION
Project, Program,
or System Name:

FEMA Individual Assistance (IA) FEMA-Administered Disaster Case
Management (DCM) Program

Component or
Office:

Federal Emergency
Management Agency (FEMA)

Office or
Program:

Office of Response and
Recovery

FISMA Name (if
applicable):

N/A

FISMA
Number (if
applicable):

N/A

Type of Project or
Program:

Program

Project or
program
status:

Existing

March 1, 2013

Pilot launch
date:

N/A

N/A

Pilot end date:

N/A

N/A

Expected
ATO/ATP/OA
date (if
applicable):

N/A

Date first
developed:
Date of last PTA
update
ATO Status (if
applicable):1

PROJECT, PROGRAM, OR SYSTEM MANAGER
Name:
Office:
Phone:

Zach Usher
Mass Care/Voluntary Agency
Liaison/Community Services
(MCVCS)
202-834-6791

Title:

MCVCS Branch Chief

Email:

[email protected]

INFORMATION SYSTEM SECURITY OFFICER (ISSO) (IF APPLICABLE)

1

Name:

Click here to enter text.

Phone:

Click here to enter text.

Email:

Click here to enter text.

The DHS OCIO has implemented a streamlined approach to authorizing an Authority to Operate (ATO), allowing for rapid deployment of new
IT systems and initiate using the latest technologies as quickly as possible. This approach is used for selected information systems that meet the
required eligibility criteria in order to be operational and connect to the network. For more information, see
http://dhsconnect.dhs.gov/org/comp/mgmt/ocio/ciso/CISO%20ALL%20Documents/Authority%20to%20Proceed%20Memo%20Phase%20II.pdf.

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

Privacy Threshold Analysis
Version number: 06-2020
Page 3 of 60

SPECIFIC PTA QUESTIONS
1. Reason for submitting the PTA: New PTA

The Federal Emergency Management Agency (FEMA) submits this Privacy Threshold Analysis
(PTA) to discuss the FEMA-administered Disaster Case Management (DCM) Program. FEMAadministered DCM is managed by FEMA’s Individual Assistance (IA) Division under the
Stafford Act. Specifically, Section 426 of the Stafford Act authorizes FEMA to “provide case
management services, including financial assistance, to State or local government agencies or
qualified private organizations to provide such services to victims of major disasters to identify
and address unmet needs.” A disaster-caused unmet need is “[a]ny un-resourced item, support, or
assistance that has been assessed and verified as necessary for a survivor to recover from
disaster. This may include food, clothing, shelter, first aid, emotional and spiritual care,
household items, home repair, or rebuilding.” See Individual Assistance Program and Policy
Guide, Ch. 4, at p. 172.2
FEMA may administer DCM directly or through a FEMA-selected provider. Alternatively,
FEMA may provide financial assistance through a federal award to a state, tribe, or territory
(hereafter “state”) to allow for state-administered DCM. This PTA does not address stateadministered DCM—only FEMA-administered DCM.
In a FEMA-administered DCM program in which FEMA does not provide direct services,
FEMA assesses the available entities to perform the work and evaluates those entities against the
size and scope of the disaster and subsequent unmet needs to execute the mission and best
support the survivors. FEMA then selects a provider in coordination with the state to implement
DCM on behalf of FEMA (hereafter “chosen provider”). A chosen provider to implement
FEMA-administered DCM may be:
•
•
•
•

2

a Federal agency that provides case management services, such as the Department of
Health and Human Services, Administration for Children and Families (HHS/ACF),
through a mission assignment;3
a national-level voluntary agency experienced in case management, such as the
American Red Cross, through an interagency reimbursable work agreement;
a voluntary agency providing personnel experienced in case management through
invitational travel (to pay for travel costs); or
a DCM provider with case managers contracted to work with FEMA personnel
through an existing or new FEMA contract.

Individual Assistance Program and Policy Guide Final March 2019 (fema.gov)
FEMA issues mission assignments as part of a Presidentially declared emergency or major disaster pursuant to its
authority under the Stafford Act, 42 U.S.C. § 5192(a)(1). Mission assignments allow for deployment, employment
and assistance from the full range of federal resources to support disaster needs.
3

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

Privacy Threshold Analysis
Version number: 06-2020
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The intent of the FEMA-administered DCM is to supplement services typically provided by the
state and local organizations that organically provide these services following a disaster. In most
instances, this means that FEMA may need to provide immediate services while the state
develops their DCM Federal award application and plan for supplementing existing services. As
indicated above, DCM programs implemented through a federal award from FEMA are not
FEMA-administered DCM. PII information compiled during a FEMA-administered DCM is not
typically shared with the state until the state has received the federal award. However, FEMA
may share aggregate (non-PII) information and trend data that will feed the DCM Federal award
application. In exigent circumstances, however, FEMA may need to provide longer-term services
when the state does not have the capacity to do so themselves, even with the financial assistance
from FEMA provided through the DCM Federal award. For the purposes of this PTA, FEMA
will focus on all available options in which FEMA administers DCM.
The FEMA-administered DCM can be a short-term program that provides limited services to
disaster survivors (also referred to as Immediate DCM or IDCM) or a longer program with a full
spectrum of case management services that may last for up to 24 months, or longer in exigent
circumstances, from the date IA was designated on the major disaster declaration. The purpose of
the FEMA-administered DCM is to address immediate, interim, or long-term disaster-caused
unmet needs, to include development of individual disaster recovery plans and referrals to
available resources. The typical period of performance may range from approximately 90-180
days to address immediate unmet needs, or longer to address prolonged unmet needs. Services
for survivors may generally begin as early as 14 days of the date of a disaster event. At the
conclusion of the immediate FEMA-administered DCM program, cases will typically be
transferred to a longer-term, federal award DCM program management entity (i.e., state agency)
funded by FEMA through a Federal award (e.g. a grant or cooperative agreement). When
approved, the DCM Federal award program typically takes about 180 days to award and begin
providing services to survivors.
FEMA, in consultation with the state, determines that certain disasters warrant FEMAadministered DCM services. The size of the impacted population and the scope of the disaster, as
well as the ability of local resources to adequately meet the disaster-caused unmet needs of
survivors, may be factors in determining whether a FEMA-administered DCM program is
required.
For the chosen provider performing case management functions on behalf of FEMA, FEMA
survivor registration data may be shared. When FEMA-administered DCM services are needed,
FEMA receives a data request, enters into data sharing agreements with the chosen provider, and
documents this sharing through an Information Sharing Access Agreement (ISAA).
Once the program is implemented, case managers work one-on-one with survivors to: identify
resources for unmet, disaster-related needs; assist with developing a personalized disaster

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

Privacy Threshold Analysis
Version number: 06-2020
Page 5 of 60

recovery plan; advocate for the resources needed to address their unmet needs; and schedule
recurring meetings with the survivor to confirm their status and address continued unmet needs.
In a typical case, FEMA may recommend case management for a registered disaster survivor
who lives in or was located in an IA major disaster declaration area at the time of the incident
and who self-identifies as requiring housing assistance because their primary residence was
destroyed.
FEMA will provide focused registration data to the chosen provider for the registered disaster
survivors recommended for case management services. The data is provided via encrypted file,
in an email by attachment per DHS guidelines, to the relevant chosen provider points of contact
listed in an ISAA. Source data will be extracted from the NEMIS-IA enterprise application by
the Recovery and Analytics Division (RAD) within the FEMA Office of Response and
Recovery. RAD forms the data set into an encrypted data file and sends the encrypted file via
email to the chosen provider. Alternatively, data files too large to email will be encrypted and
sent via FEMA Secure Data Sharing community on the Homeland Security Information Network
(HSIN).
The chosen provider will receive the data from FEMA typically via an encrypted email formatted
into a spreadsheet, decrypt, and temporarily save the data file. The FEMA-administered DCM
case managers then take the information from the spreadsheet and manually input it into their
proprietary systems of record, like the HHS/ACF’s Electronic Case Management Record System
(ECMRS) or the American Red Cross’ Coordinated Assistance Network (CAN). The chosen
provider will review survivor information provided by FEMA to ensure that there are no
duplicate case files or duplication of services and confirm that sparse resources and services are
distributed equitably among survivors in a timely manner so that there are no gaps in federal
support. The chosen provider does not conduct a duplication of benefits check under Section 312
of the Stafford Act, 42 U.S.C. § 5155 because the FEMA-administered DCM addresses unmet
needs and the chosen provider does not provide survivors with financial assistance.
The data fields collected from survivors to perform the FEMA-administered DCM services are
listed in Section 3. The chosen provider may use FEMA’s data:
•
•

•
•

To develop a financial assistance case for the appropriate financial assistance program so
that they can proactively engage the client and invite them to complete the necessary
application in order to process their application for financial assistance;
To ensure that case managers are supporting disaster survivors from jurisdictions
included in the IA declaration;
To conduct outreach to disaster survivors and set up appointments for intake assessments
and triage;
To help survivors navigate FEMA’s Sequence of Delivery and avoid duplication of
services;

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

Privacy Threshold Analysis
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•
•

To conduct intake assessments of disaster survivors and subsequently triage and tier
survivor cases according to the severity of the disaster needs; and
To ensure that seniors, individuals with disabilities, and others with access and functional
needs are supported.

Beyond those registered survivors referred by FEMA, the chosen provider’s case managers may
connect with survivors in disaster recovery centers, shelters, and other community locations
where there are individuals who have been impacted by the disaster and have unmet needs. Also,
in some cases, a disaster survivor may proactively contact the chosen provider themselves (e.g.
via a helpline or in-person) to obtain DCM services.
The chosen provider’s case managers will utilize the questions provided by FEMA to conduct
intake with disaster survivors. The data elements are listed in this PTA in Appendix A. The
questions are in electronic form, to be completed and used by the chosen provider’s case
managers to assess, screen (to avoid duplication of services and ensure they are eligible for
disaster-related services) and refer disaster survivors to resources that address their disasterrelated needs. The order in which the questions are asked may vary per chosen provider, as it
relates to their proprietary system of record. The chosen provider’s case managers then take the
information collected from the questions asked and manually input into their system of record.
Any system of record utilized by a chosen provider to implement DCM on behalf of FEMA must
comply with FEMA cybersecurity requirements for storing personally identifiable information
(PII)/Sensitive PII (SPII).
FEMA may receive a request from a state to gain access to a disaster survivor’s PII/SPII data
generated in a FEMA-administered DCM mission to, for instance, establish their long-term
disaster case management program. In such instances, FEMA will request that the chosen
provider transfer the data via email with an encrypted file to the DCM Federal award recipient
point of contact or will receive the data via secure file transfer from the FEMA-administered
DCM chosen provider, hold the information in an encrypted spreadsheet until the recipient is
able to receive the information, and then provide that information to the state via secure file
transfer after ratifying the appropriate ISAA with the requesting entity.

Case managers may require verification documents (i.e. license) to validate the pre-disaster
address of survivors and validate their identity. They do not collect survivor documentation for
this field. Nothing is copied, scanned, or retained. Case managers will just view the identification
and confirm with whom they are speaking.

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

Privacy Threshold Analysis
Version number: 06-2020
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There are two potential outcomes once an individual is found to need services. In the first
outcome, a survivor satisfactorily receives a referral4 to resources to meet their needs, and the
case is closed. In the second outcome, a survivor may opt to work with the case manager to
create a personalized disaster recovery plan and meet, as needed, to address their disaster-caused
unmet needs. A disaster recovery plan is a goal-oriented plan for recovery that will assist with
prioritizing the unmet needs in order of urgency and provide referrals to resources to address
those needs. Survivors can receive free assistance from disaster case managers on how to access
critical resources and on how best to recover from disasters and their aftermath, along with ways
to access a variety of available resources. The FEMA-administered DCM chosen provider will
provide the survivor with a FEMA consent form and may share their information with Long
Term Recovery Groups (LTRG), voluntary entities, or the DCM federal award recipient. FEMA
plans to draft a new FEMA-administered DCM consent form.
Case managers may refer disaster survivors to groups that provide necessary resources, such as
food, clothing, furniture, appliances, transportation, employment, financial assistance, health
insurance, medical equipment, legal referral services, senior services, behavior health services,
and child and youth services. The case manager will triage the case to determine how often the
case manager and survivor should meet to check on the progress of the disaster recovery plan
and the status of their disaster-caused unmet needs.
When referring disaster survivors to a voluntary recovery group as part of the FEMAadministered DCM program, the chosen provider may share applicable information, that may
include PII, with the voluntary recovery group after the survivor has provided written consent to
share. Once the FEMA-administered DCM program has closed, the chosen provider will share
the case files with a long-term Disaster Case Management federal award recipient so that they
can continue to provide assistance to these individuals, as mentioned previously.
In sum, disaster case managers connect survivors to available resources to address their disastercaused unmet needs. This includes resources provided by voluntary organizations, FEMA, and
other federal, state, and local entities. Case managers meet with survivors to provide referral
information and develop a recovery plan that prioritizes next steps the survivor should take in
accessing resources, as well as follow-up as needed, to ensure survivors follow through, and to
provide additional information to address any continued unmet needs. FEMA is working to
develop a FEMA-administered DCM guidance document to outline proper data collection and
sharing and to include information technology security requirements, in addition to ISAAs, that
can be socialized in the readiness phase as well as the program execution phase.

4

FEMA provides the contact information of an organization that has resources available to meet the survivor’s needs.
For example, if the individual needs shelter, information on the hours and location of the shelter is provided.

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

Privacy Threshold Analysis
Version number: 06-2020
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☐ This project does not collect, collect, maintain,
use, or disseminate any personally identifiable
information5

☒ Members of the public
☒ U.S. Persons (U.S citizens or lawful

2. From whom does the Project, Program,
or System collect, maintain, use, or
disseminate information?
Please check all that apply.

permanent residents)

☒ Non-U.S. Persons
☐ DHS Employees/Contractors (list Components):
Click here to enter text.

☒ Other federal employees or contractors (list
agencies): Chosen provider’s
Employees/Contractors

☒ No
2(a) Is information meant to be
collected from or about
sensitive/protected populations?

☐ 8 USC § 1367 protected individuals (e.g., T, U,
VAWA)6

☐ Refugees/Asylees
☐ Other. Please list: Click here to enter text.

3. What specific information about individuals is collected, maintained, used, or
disseminated?

DHS defines personal information as “Personally Identifiable Information” or PII, which is any information that permits the identity of an
individual to be directly or indirectly inferred, including any information that 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. “Sensitive PII” is PII, which
if lost, compromised, or disclosed without authorization, could result in substantial harm, embarrassment, inconvenience, or unfairness to an
individual. For the purposes of this PTA, SPII and PII are treated the same.
6
This involves the following types of individuals: T nonimmigrant status (Victims of Human Trafficking), U nonimmigrant status (Victims of
Criminal Activity), or Violence Against Women Act (VAWA). For more information about 1367 populations, please see: DHS Management
Directive 002-02, Implementation of Section 1367 Information Provisions, available at
http://dhsconnect.dhs.gov/org/comp/mgmt/policies/Directives/002-02.pdf.
5

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

Privacy Threshold Analysis
Version number: 06-2020
Page 9 of 60

FEMA will provide the following focused registration data (via encrypted file in an email via
attachment per DHS guidelines) to the relevant points of contact listed in an Information Sharing
and Access Agreement (ISAA):
Registrant Name
FEMA Registration Number
Disaster Number
Damaged County
Registrant Damaged Dwelling (DD) Address
Registrant DD City of Residence
Registrant DD Zip Code
Registrant Current Mailing Address (CMA) Street
Registrant CMA City
Registrant CMA Zip Code
Registrant Primary Phone Number
Registrant Alternate Phone Number
Real Property FEMA Verified Loss
Personal Property FEMA Verified Loss
Total FEMA Verified Loss
Self-Reported Income
Home Owners Insurance (HOI)/Renters Insurance – Y/N
Flood Insurance – Y/N
Small Business Administration (SBA) Status – Status Code
Approved Housing Assistance (HA) - Amount
Approved Other Needs Assessment (ONA) – Amount
Approved Individuals and Households Program (IHP) - Amount
Household (HH) Size
HH Member <=7
HH Member >=65
Household Ages
Emergency Need (During the Registration Intake the individual can mark Yes for Emergency Need then
say yes to food, shelter and clothing. The information is not used for IHP or ONA eligibility. It is stored
to potentially make referrals to FEMA partners).
Access and Functional Need (yes/no, if Yes is selected, the following hierarchy selections result in
Category, Type: EAR, AID / EAR, SIGN / EAR, TMSG / EAR, TTY / EYE, CANE / EYE,
COM_DVC / EYE, MAG / EYE, SPECS / EYE, SVC_ANIM / MENTAL, OTH / MENTAL, PCA
MOBILITY, B_CHAIR / MOBILITY, CANE / MOBILITY, LIFT / MOBILITY, PCA / MOBILITY,
WALKER / MOBILITY, W_CHAIR / OTH, OTH
Current Location (The following Selections are available: My Vehicle, Church/House of Worship, My
Home, Place of Employment, Family/Friends, Hotel/Motel, FEMA Provided Unit, Homeless, Purchased

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

Privacy Threshold Analysis
Version number: 06-2020
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New Home, New Permanent Rental, New Temporary Rental, Recreational Vehicle (RV)/Camper, Mass
Shelter, Secondary Residence, Tent, Other
The following data elements are collected by chosen providers from the FEMA-administered DCM
applicant on the Client Consent:
Disaster Survivor Name
Signature Head of Household or Verbal Consent
Signature Co-Applicant
In addition to the focused registration data, FEMA will authorize DCM providers to collect data
elements necessary for FEMA to administer the DCM program. These data elements will be
contained in a pending OMB approved collection and pending DCM SORN. See Appendix A for
full list of DCM data elements that may be collected.

3(a) Does this Project, Program, or System collect, maintain, use, or disseminate Social Security
numbers (SSN) or other types of stand-alone sensitive information?7 If applicable, check all
that apply.

☐ Social Security number
☐ Alien Number (A-Number)
☐ Tax Identification Number
☐ Visa Number
☐ Passport Number
☐ Bank Account, Credit Card, or other
financial account number
☐ Driver’s License/State ID Number
3(b) Please provide the specific legal basis
for the collection of SSN:

7

☐ Social Media Handle/ID
☐ Driver’s License/State ID Number
☐ Biometric identifiers (e.g., FIN, EID)
☐ Biometrics.8 Please list modalities (e.g.,
fingerprints, DNA, iris scans): Click here to
enter text.
☐ Other. Please list: Click here to enter
text.
N/A

Sensitive PII (or sensitive information) is PII that if lost, compromised, or disclosed without authorization, could result in substantial harm,
embarrassment, inconvenience, or unfairness to an individual. More information can be found in the DHS Handbook for Safeguarding Sensitive
Personally Identifiable Information, available at https://www.dhs.gov/publication/handbook-safeguarding-sensitive-personally-identifiableinformation.
8
If related to IDENT/HART and applicable, please complete all Data Access Request Analysis (DARA) requirements. This form provides
privacy analysis for DHS’ IDENT, soon to be HART. The form replaces a PTA where IDENT is a service provider for component records. PRIV
uses this form to better understand how data is currently shared, will be shared and how data protection within IDENT will be accomplished.
IDENT is a biometrics service provider and any component or agency submitting data to IDENT is a data provider.

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

Privacy Threshold Analysis
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3(c) If the SSN is needed to carry out the functions and/or fulfill requirements of the Project,
System, or Program, please explain why it is necessary and how it will be used.
N/A
3(d) If the Project, Program, or System requires the use of SSN, what actions are being taken to
abide by Privacy Policy Instruction 047-01-010, SSN Collection and Use Reduction,9 which
requires the use of privacy-enhancing SSN alternatives when there are technological, legal, or
regulatory limitations to eliminating the SSN? Note: even if you are properly authorized to collect
SSNs, you are required to use an alternate unique identifier. If there are technological, legal, or
regulatory limitations to eliminating the SSN, privacy-enhancing alternatives should be taken, such as
masking, truncating, or encrypting the SSN, or blocking the display of SSNs in hard copy or digital
formats.
N/A

☒ By a unique identifier.10 Please list all unique

4. How does the Project, Program, or
System retrieve information?

5. What is the records retention
schedule(s) for the information
collected for each category type (include
the records schedule number)? If no
schedule has been approved, please
provide proposed schedule or plans to
determine it.
Note: If no records schedule is in place or are unsure
of the applicable records schedule, please reach out to
the appropriate Records Management Office.12

9

identifiers used:
FEMA Registration ID/Number, DCM client unique
identification number11, Registrant/DCM client
name, pre-disaster damaged dwelling address
(street, city, state, zip code)
☐ By a non-unique identifier or other means. Please
describe:
Click here to enter text.
IA program registration data:
DAP 8-1 Headquarters Activity (Disaster Assistance
Program - Individual Assistance (IA) Division)
Files.
IA Program Files. (All IA program files except
those relating to temporary housing and IFG
programs. They include other programs such as
Disaster Unemployment Assistance (DUA), Crisis
Counseling and Training, Legal Services,
Superfund, Flood Plain Management, Duplication of

See https://www.dhs.gov/publication/privacy-policy-instruction-047-01-010-ssn-collection-and-use-reduction.
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.
11
All FEMA-administered DCM chosen provider clients receive a number just like FEMA registrants receive a registration ID
12
See http://dhsconnect.dhs.gov/org/comp/mgmt/ocio/IS2O/rm/Pages/RIM-Contacts.aspx
10

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

Privacy Threshold Analysis
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Benefits, and the Cora Brown Fund).
TEMPORARY. Retire to inactive storage when 2
years old. Destroy when 6 years 3 months old. N1311-86-1, Item 4C10a
DAP 8-2 Headquarters Activity (Disaster Assistance
Program ‑ Individual Assistance (IA) Division)
Files.
Temporary Housing Files. Copies of computer
printouts scoreboards, Federal Coordinating
Officer's digests, correspondence, and related
records.
TEMPORARY. Destroy 3 years after close of the
operation (when database elements have been
defined).
N1-311-86-1, Item 4C10b
Records will be kept on a permanent schedule until
the records can be placed in a records category
and/or a new records schedule is approved by
NARA.

Recovery manages all enterprise Recovery systems
through system owners and information systems
security officers (ISSO) and ensures manual audits
are performed pursuant to an audit schedule.
5(a) How does the Project, Program, or
System ensure that records are
disposed of or deleted in accordance
with the retention schedule (e.g.,
technical/automatic purge, manual audit)?

Records will be kept on a permanent schedule until
the records can be placed in a records category
and/or a new records schedule is approved by
NARA.
Applicable retention schedule provided to entities
performing DCM/IDCM services on behalf of
FEMA in applicable agreements (i.e. contracts,
ISAAs, etc.)

6. Does this Project, Program, or System
connect, receive, or share PII with any

☐ No.

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U.S. Department of Homeland Security
Washington, DC 20528
202-343-1717, [email protected]
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Privacy Threshold Analysis
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other DHS/Component projects,
programs, or systems?13

☒ Yes. If yes, please list:
HSIN

☐ No.
☒ Yes. If yes, please list: The chosen provider may

7. Does this Project, Program, or System
connect, receive, or share PII with any
external (non-DHS) government or
non-government partners or systems?

8. Is this sharing pursuant to new or
existing information sharing agreement
(MOU, MOA, LOI, RTA, etc.)? If
applicable, please provide agreement as
an attachment.

share PII/SPII with LTRG and Federal Award
Recipients. FEMA may receive a request from a
state to gain access to disaster survivor’s PII/SPII
data generated in a FEMA-administered DCM
mission to, for instance, establish their long-term
disaster case management program. In such cases,
FEMA will receive the data via secure file transfer
from the chosen provider, hold the information in an
encrypted spreadsheet until the recipient is able to
receive the information, and then provide that
information to the state via secure file transfer after
ratifying the appropriate ISAA with the requesting
entity.

Please describe applicable information sharing
governance in place: Pursuant to FEMAadministered DCM mechanism (i.e. mission
assignment, contract, etc.) and ISAA with the
chosen provider, The provider may further share
with LTRG and Federal Award Recipients pursuant
to an separate ISAA or a consent form. FEMA may
share PII/SPII with a state after ratifying the
appropriate ISAA with the requesting entity.

☐ No. What steps will be taken to develop and
9. Does the Project, Program, or System
or have a mechanism to track external
disclosures of an individual’s PII?

13

maintain the accounting:
☒ Yes. In what format is the accounting
maintained: FEMA RAD tracks all disclosures of
datasets from generated reports. Additionally,
FEMA’s Disclosure Branch tracks disclosures of PII
from FEMA.

PII may be shared, received, or connected to other DHS systems directly, automatically, or by manual processes. Often, these systems are listed
as “interconnected systems” in IACS.

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The chosen provider would document in the case
file when they share with an external entity such as
a state.

10. Does this Project, Program, or System
use or collect data involving or from
any of the following technologies:

☐ Social Media
☐ Advanced analytics14
☐ Live PII data for testing
☒ No

11. Does this Project, Program, or System
use data to conduct electronic searches,
queries, or analyses in an electronic
database to discover or locate a
predictive pattern or an anomaly
indicative of terrorist or criminal
activity on the part of any individual(s)
(i.e., data mining)?15 This does not
include subject-based searches.
11(a) Is information used for research,
statistical, or other similar purposes? If so,
how will the information be de-identified,
aggregated, or otherwise privacyprotected?

☒ No.

12. Does the planned effort include any

☒ No.

interaction or intervention with human
14

☐ Yes. If yes, please elaborate: Click here to enter
text.

☒ No.
☐ Yes. If yes, please elaborate: Click here to
enter text.

The autonomous or semi-autonomous examination of Personally Identifiable Information using sophisticated techniques and tools to draw
conclusions. Advanced Analytics could include human-developed or machine-developed algorithms and encompasses, but is not limited to, the
following: data mining, pattern and trend analysis, complex event processing, machine learning or deep learning, artificial intelligence, predictive
analytics, big data analytics.
15
Is this a program involving pattern-based queries, searches, or other analyses of one or more electronic databases, where—
(A) a department or agency of the Federal Government, or a non-Federal entity acting on behalf of the Federal Government, is conducting
the queries, searches, or other analyses to discover or locate a predictive pattern or anomaly indicative of terrorist or criminal activity on the part of
any individual or individuals;
(B) the queries, searches, or other analyses are not subject-based and do not use personal identifiers of a specific individual, or inputs
associated with a specific individual or group of individuals, to retrieve information from the database or databases; and
(C) the purpose of the queries, searches, or other analyses is not solely—
(i) the detection of fraud, waste, or abuse in a Government agency or program; or
(ii) the security of a Government computer system.

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Privacy Threshold Analysis
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subjects16 via pilot studies, exercises,
focus groups, surveys, equipment or
technology, observation of public
behavior, review of data sets, etc. for
research purposes

☐ Yes. If yes, please reach out to the DHS
Compliance Assurance Program Office (CAPO) for
independent review and approval of this effort.17

13. Does the Project, Program, or System
provide role-based or additional
privacy training for personnel who
have access, in addition to annual
privacy training required of all DHS
personnel?

☐ No.

14. Is there a FIPS 199 determination?18

☒ No.

☒ Yes. If yes, please list: Case managers receive
specialized training that includes Agency cyber
security and privacy physical device and data
protections.

☐ Yes. Please indicate the determinations for each
of the following:
Confidentiality:
☐ Low ☐ Moderate ☐ High ☐ Undefined
Integrity:
☐ Low ☐ Moderate ☐ High ☐ Undefined
Availability:
☐ Low ☐ Moderate ☐ High ☐ Undefined

PRIVACY THRESHOLD REVIEW
(TO BE COMPLETED BY COMPONENT PRIVACY OFFICE)

16

Human subject means a living individual about whom an investigator conducting research: (1) obtains information or biospecimens through
intervention or interaction with the individual, and uses, studies, or analyzes the information or biospecimens; or (2) obtains, uses, studies, analyzes,
or generates identifiable private information or identifiable biospecimens.
17
For more information about CAPO and their points of contact, please see: https://www.dhs.gov/publication/compliance-assurance-programoffice or https://collaborate.st.dhs.gov/orgs/STCSSites/SitePages/Home.aspx?orgid=36. For more information about the protection of human
subjects, please see DHS Directive 026-04: https://www.dhs.gov/sites/default/files/publications/mgmt/general-science-and-innovation/mgmtdir_026-04-protection-of-human-subjects_revision-01.pdf.
18
FIPS 199 is the Federal Information Processing Standard Publication 199, Standards for Security Categorization of Federal Information and
Information Systems and is used to establish security categories of information systems.

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Component Privacy Office Reviewer:

Hasan Mansori

Date submitted to Component Privacy
Office:

November 3, 2020

Concurrence from other Component
Reviewers involved (if applicable):
Date submitted to DHS Privacy Office:
Component Privacy Office Recommendation:
Please include recommendation below, including what new privacy compliance documentation is needed,
as well as any specific privacy risks/mitigations, as necessary.
FEMA privacy recommends this program and information sharing activity be considered privacy
sensitive with the following compliance coverage:
▪

PIA: Interim coverage under DHS/FEMA/PIA-049 Individual Assistance (IA) Program. Privacy
will work with ORR to develop a new PIA, tentatively titled Disaster Case Management Program,
over the next 12 months.

▪

SORN: Partial coverage under DHS/FEMA-008 Disaster Recovery Assistance Files System of
Records, 78 Fed. Reg. 25282 (Apr. 2013). This SORN should cover the information shared from
FEMA to HHS. FEMA proposes a new SORN, tentatively titled FEMA-Administered Disaster
Case Management, to cover additional information beyond the scope of the FEMA Individuals
and Households program.

▪

PAS: FEMA Privacy recommends that the program work with the FEMA Information
Management Division to develop a PRA package, which shall include a collection instrument,
and a Privacy Act e(3) Statement.
(TO BE COMPLETED BY THE DHS PRIVACY OFFICE)

DHS Privacy Office Reviewer:

Joseph Thomas

DHS Privacy Office Approver (if
applicable):

Riley Dean

Workflow Number:

Click here to enter text.

Date approved by DHS Privacy Office:

March 31, 2021

PTA Expiration Date

March 31, 2022
DESIGNATION

Privacy Sensitive System:
Category of System:

Yes
Program
If “other” is selected, please describe: Click here to enter text.

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Determination:

☐ Project, Program, System in compliance with full coverage
☐ Project, Program, System in compliance with interim coverage
☐ Project, Program, System in compliance until changes implemented
☒ Project, Program, System not in compliance

PIA:
SORN:

New PIA is required.
New PIA regarding Disaster Case Management Program anticipated
New SORN is required.

New SORN concerning Administered Disaster Case Management anticipated
DHS Privacy Office Comments:
Please describe rationale for privacy compliance determination above, and any further action(s) that
must be taken by Component.
FEMA is submitting this PTA to discuss the Disaster Case Management (DCM) Program. FEMAadministered DCM is managed by FEMA’s Individual Assistance (IA) Division to “provide case
management services, including financial assistance, to State or local government agencies or qualified
private organizations to provide such services to victims of major disasters to identify and address unmet
needs,” including food, clothing, shelter, first aid, home repair, and other services.
This PTA does not address state-administered DCM—only FEMA-administered DCM. In a FEMAadministered DCM program in which FEMA does not provide direct services, FEMA assesses the
available entities to perform the work and evaluates those entities against the size and scope of the
disaster and subsequent unmet needs to execute the mission and best support the survivors.
The intent of the FEMA-administered DCM is to supplement services typically provided by the state and
local organizations that provide these services following a disaster. PII compiled during a FEMAadministered DCM is not typically shared with the state until the state has received the federal award;
however, FEMA may share aggregate information.
FEMA will provide registration data to the chosen provider for the registered disaster survivors
recommended for case management services. Source data will be extracted from the NEMIS-IA
enterprise application by the Recovery and Analytics Division within the FEMA Office of Response and
Recovery.
FEMA may receive a request from a state to gain access to a disaster survivor’s PII/SPII data generated in
a FEMA-administered DCM mission to establish their long-term disaster case management program. The
FEMA-administered DCM chosen provider will provide the survivor with a FEMA consent form and
may share their information with other entities; DHS PRIV expects that FEMA will draft a new
FEMA-administered DCM consent form.
When case managers refer disaster survivors to a voluntary recovery group as part of the FEMAadministered DCM program, the chosen provider may share applicable information, that may include PII,
with the voluntary recovery group after the survivor has provided written consent to share. DHS PRIV

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anticipates that FEMA will develop a FEMA-administered DCM guidance document to outline
proper data collection and sharing and to include information technology security requirements.
DHS PRIV concurs that this constitutes a privacy-sensitive system, and requires PIA and SORN
coverage. Although this PTA is being adjudicated with an expiration of 1-year, this program is not
in compliance until the PIA and SORN requirements are completed. These compliance artifacts
must be completed to be in compliance with the Privacy Act or E-government Act; current PIA and
SORN coverage for other FEMA programs related to assistance is insufficient for the scope of the
program’s collection. A new PIA regarding Disaster Case Management Program and a new SORN
regarding Administered Disaster Case Management are anticipated in order to bring this program into
compliance. DHS PRIV will update the adjudication once the PIA and SORN requirements are fulfilled.

APPENDIX A: FEMA-ADMINISTERED DCM REGISTRATION DATA ELEMENTS
•

Caseworker’s Name,

•

Caseworker’s work phone #

•

Caseworker’s work location

•

Disaster number

•

Consent Form
o Date received

•

Applicant’s full name
o Full name
o Alias/Preferred Name

•

Co-Applicant’s full name and/or other household residents
o Full name
o Alias/Preferred Name

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o Relationship to applicant, for example:
▪

Aunt

▪

Father

▪

Grandfather

▪

Guardian

▪

Other adult

▪

Son

▪

Stepsister

▪

Brother

▪

Foster parent

▪

Grandmother

▪

Husband

▪

Other child under 18

▪

Stepbrother

▪

Stepson

▪

Caregiver/nurse

▪

Foster son

▪

Great grandchild

▪

Mother

▪

Other relative

▪

Stepdaughter

▪

Uncle

▪

Daughter

▪

Foster daughter

▪

Great grandfather

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▪

Nephew

▪

Self

▪

Stepfather

▪

Wife

▪

Domestic partner

▪

Grandchild

▪

Great grandmother

▪

Niece

▪

Sister

▪

Stepmother

o Alternate Contact (Y/N)
▪
•

Age

•

Gender

If Y, best number to contact

o Male
o Female
o Undetermined
o Declined
•

Preferred Language

Contact Information to include damaged dwelling, current address, and other applicable
addresses
• Address
•

Apt/Suite

•

Address Type, for example:
o Apartment or house that you own

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o Community shelter
o Public housing
o Retirement community
o Other
o Room, apartment, or house that you rent
o Community Transitional Housing
o Nursing or Assisting Living Facility
o Hotel or motel
o Undetermined
o Staying or living the home of a family member/friends
o Hospital
o Place not meant for habitation/Homeless
o Declined
•

Number of other individuals in household

•

Email Addresses

•

Phone Numbers

•

Location Status, for example:
o Begin date
o End date

•

Self-Reported Special/At-Risk Populations, for example:
o Children
o Elderly
o Individuals with limited English proficiency
o Individual with disabilities in the household

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o Shelter
o Other
•

Self-Identified Unmet Needs, include those that apply. For example:
o Behavioral health access
o Finances
o Legal
o Clothing
o Furniture and/or appliances
o Transportation
o Employment
o Health insurance or healthcare access
o Food
o FEMA Help
o Housing
o Other

•

FEMA Tier, include case manager designated FEMA Tier.
o Tier 1 – Immediate Needs Met
o Tier 2 – Some Remaining Unmet Needs or in Current Rebuild/Repair Status
o Tier 3 – Significant Unmet Needs
o Tier 4 – Immediate and Long-Term Unmet Needs

•

FEMA Registration Number

•

Disaster Survivor Case Status, for example:
o Active case
o Information/Referral Only

•

Assigned Case Worker

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o Work phone
o Work location
Assistance and Referral Information
Behavioral Health Assessment
• Assessment Date
•

Is Disaster Survivor or anyone in the household in distress?
o Yes
o No
o Undetermined
o Declined

•

Would Disaster Survivor or anyone in the household like to speak to someone about
coping with disaster-related stress?
o Yes
o No
o Undetermined

•

Referral Needed?
o Yes
o No
o Undetermined
o Declined

•

Referral Services, note all that apply. For example:
o Behavioral health – other
o Crisis counseling program
o Community clinical provider
o Disaster distress helpline

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o Counseling services
o Private counsel directory
o Notes – open text: Names of those in distress and a brief description of survivor
self-reported symptoms/feelings of distress
Children and Youth Assessment
• Assessment Date
•

Is the disaster survivor caring for a foster child or foster children?
o Yes
o No
o Undetermined
o Declined

•

Prior to the disaster, was the disaster survivor’s child in early education?
o Yes
o No
o Undetermined
o Declined

•

Prior to the disaster, was the disaster survivor’s child in childcare?
o Yes
o No
o Undetermined
o Declined

•

If yes, were the services disrupted as a result of the disaster?
o Yes
o No
o Undetermined

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o Declined
•

Does the disaster survivor currently have a need for childcare?
o Yes
o No
o Undetermined
o Declined

•

If childcare is needed but child is not attending, what are the barriers?
o Childcare provider closed due to the disaster
o Disaster survivor relocated to new area
o Disaster survivor unable to find childcare for child with disability
o Community barriers because of disaster
o Increased childcare costs
o Disaster survivor now unable to afford childcare due to unemployment losses
o Disaster survivor unable to access site due to transportation
o Disaster survivor unable to find childcare for infant
o Family care provider can no longer provide care post disaster

•

Prior to the disaster, did disaster survivor get voucher assistance for childcare?
o Yes
o No
o Undetermined
o Declined

•

Are the disaster survivor’s children currently attending school?
o Yes
o No
o Undetermined

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o Declined
•

If disaster survivor’s children currently attending school, are they in the same school
district post-disaster?
o Yes
o No
o Undetermined
o Declined

•

Has your child missed any scheduled checkups or immunizations since the disaster?
o Yes
o No
o Undetermined
o Declined

•

Does disaster survivor have any concerns about how his/her child is managing feelings
and behaviors post-disaster?
o Yes
o No
o Undetermined
o Declined

•

If yes, please explain in detail.

•

Referral Needed?
o Yes
o No
o Undetermined
o Declined

•

Referral Services, note all that apply
o Case manager advocacy

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o Childcare
o Referral to childcare and referral agency
o Referral to social services
o School district
o Child-other
o Referral to early education
o Referral to disaster distress helpline
o Referral to Voluntary Organization Active in Disasters (VOAD)/community
group for school supplies
•

Notes
o Open text

FEMA/SBA Assessment
• Does disaster survivor have a FEMA Registration number?
o Disaster survivor has not received
o Disaster survivor received envelope but threw away
o Does not know
o Yes
o No
•

Small Business Administration (SBA) Application
o Disaster survivor has submitted SBA application
▪

Yes

▪

No

▪

Undetermined

▪

Declined

▪

If yes, SBA Application Submitted Date

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o Disaster survivor has been approved for SBA loan
▪

Yes

▪

No

▪

Undetermined

▪

Declined

▪

If yes, Date Approved

o Disaster survivor has registered for FEMA Individual Assistance
▪

Yes

▪

No

▪

Undetermined

▪

Declined

▪

If yes, Submitted Claim Date

o Disaster survivor has received non-compliance notice from FEMA Individual
Assistance (IA)
▪

Yes

▪

No

▪

Undetermined

▪

Declined

▪

If yes, non-compliance notice received date

o Disaster survivor has received FEMA IA Benefit
▪

Yes

▪

No

▪

Undetermined

▪

Declined

▪

If yes, IA benefit received date

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o Disaster survivor has received MAX Grant from FEMA
▪

Yes

▪

No

▪

Undetermined

▪

Declined

▪

If yes, max grant received date

o Disaster survivor has applied for FEMA Other Needs Assistance (ONA)
▪

Yes

▪

No

▪

Undetermined

▪

Declined

▪

If yes, ONA application date

o Disaster survivor has received ONA
▪

Yes

▪

No

▪

Undetermined

▪

Declined

▪

If yes, ONA received date

o Disaster Survivor was denied for ONA
▪

Yes

▪

No

▪

Undetermined

▪

Declined

▪

If yes, ONA denied date

o Referral Needed?

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▪

Yes

▪

No

▪

Undetermined

▪

Declined

o Referral Services, note all that apply.
▪

Assist with appeal for SBA denial

▪

Assist with completion of FEMA ONA Application

▪

Assist with FEMA IA denial

▪

Assist with FEMA/SBA Sequence of Delivery

▪

FEMA – Other

▪

Provide education regarding FEMA/SBA Sequence of Delivery

▪

Submit inquiry to FEMA IA Branch re: Disaster Survivor’s ONA
Application

▪

Assist with completion of FEMA IA Application

▪

Assist with completion of SBA Loan Applications

▪

Assist with FEMA ONA denial

▪

Case manager assistance

▪

Obtain signed FEMA Disclosure release from Disaster Survivor

▪

Submit inquiry to FEMA IA Branch re: Disaster Survivor’s IA
Application

o Notes
▪

Open text

Clothing Assessment
• Did any of the household members lose clothing as a result of the disaster?
o Yes
o No

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o Undetermined
o Declined
•

If yes, did disaster survivor submit a claim for the clothes with the insurance company (if
has coverage)?
o Yes
o No
o Undetermined
o Declined

•

Does disaster survivor/family have useable clothing and shoes for work or school?
o Yes
o No
o Undetermined
o Declined

•

Does disaster survivor/family have clothing appropriate for current weather conditions?
o Yes
o No
o Undetermined
o Declined

•

Referral needed
o Yes
o No
o Undetermined
o Declined

•

Referral Services, note all that apply. For example:
o Assistance with FEMA ONA

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o Clothing – Other
o Laundry Assistance
o Voucher
o Assistance with insurance claim/appeal
o Clothing and other personal items
o Referral to faith-based/community organization for clothing
•

Notes:
o Open text – may include age, types and sizes of clothing/shoes needed

Employment Assessment
• Pre-disaster employment assessment
o Assessment date
o Previously employed?
▪

Yes

▪

No

▪

Undetermined

▪

Declined

o Looking for additional employment/increased hours?

•

▪

Yes

▪

No

▪

Undetermined

▪

Declined

Post-disaster employment assessment
o Assessment date
o Did you lose your job because of the disaster?
▪

Yes

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▪

No

▪

Undetermined

▪

Declined

o Currently employed?
▪

Yes

▪

No

▪

Undetermined

▪

Declined

o Looking for additional employment/increased hours?
▪

Yes

▪

No

▪

Undetermined

▪

Declined

o Has disaster survivor applied for FEMA Disaster Unemployment Assistance?
▪

Yes

▪

No

▪

Undetermined

▪

Declined

o If yes, was Disaster Unemployment Assistance approved?
▪

Yes

▪

No

▪

Undetermined

▪

Declined

o If yes, was Disaster Unemployment Assistance denied?
▪

Yes

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▪

No

▪

Undetermined

▪

Declined

o Referral needed?
▪

Yes

▪

No

▪

Undetermined

▪

Declined

o Referral Services, note all that apply.
▪

Education

▪

Employment placement service

▪

Employment – other

▪

Job searching resources

o Notes (e.g. include information necessary to address the need)
Financial Assessment
• Evaluation Date
•

Family Size

•

Pre-Disaster Financial Assessment, for example:
o Annual Household Income Range
▪

$0-14,999

▪

$15,000-24,999

▪

$25,000-39,999

▪

$40,000-49,999

▪

$50,000-74,999

▪

$75,000-99,999

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▪

$100,000-149,999

▪

$150,000+

o Monthly income (open text)
o Monthly expenses (open text)
o Pre-Disaster, was disaster survivor or any household member receiving any of the
following? Note as many as apply

•

▪

Unemployment insurance

▪

Supplemental security income (SSI)

▪

Veterans disability payment

▪

Social security disability income (SSDI)

Post-Disaster Financial Assessment, for example:
o Estimated annual household income range
▪

$0-14,999

▪

$15,000-24,999

▪

$25,000-39,999

▪

$40,000-49,999

▪

$50,000-74,999

▪

$75,000-99,999

▪

$100,000-149,999

▪

$150,000+

o Post-Disaster, is disaster survivor or any household member receiving any of the
following? note as many as apply
▪

Unemployment insurance

▪

Supplemental security income (SSI)

▪

Veterans disability payment

▪

Social security disability income (SSDI)

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o Disaster Unemployment Assistance received?
▪

Yes

▪

No

▪

Undetermined

▪

Declined

o If yes, amount (open text)
o If yes, duration (open text – start and end dates)
o Referral needed?
▪

Yes

▪

No

▪

Undetermined

▪

Declined

o Referral services, note as many as apply
▪

Disaster Unemployment Assistance

▪

Financial – other

▪

Grant Assistance

o Notes (include necessary information to address the need)
Food Assessment
• Does Disaster Survivor have enough food to feed all members of the household
o Yes
o No
o Undetermined
o Declined
•

Pre-Disaster, was disaster survivor or any household member receiving food assistance?
Note as many as apply.

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o Assistance from local pantries/food banks
o Other
o Woman infants & children (WIC) benefits
o Meals on wheels
o Supplemental nutrition assistance program (SNAP)
•

Other Food Assistance (include any necessary information to address food needs)

•

Since the disaster, has the disaster survivor requested help with food from anyone?
o Yes
o No
o Undetermined
o Declined

•

Referral needed?
o Yes
o No
o Undetermined
o Declined

•

Referral services, note as many as apply
o Assistance with D-SNAP application
o Food bank/pantry
o Referral to community organizations for food needs
o Referral to senior meals on wheels services
o Food-other
o Food delivery services
o Referral to mass care assistance for immediate food needs
o Social services for WIC/SNAP/D-SNAP

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•

Notes (include any necessary information needed to meet the need)

Furniture and Appliances Assessment
• Did disaster survivor have furniture or home appliances destroyed in the disaster?
o Yes
o No
o Undetermined
o Declined
•

If yes, did disaster survivor submit a claim for the furniture and appliance with their
insurance (if any)?
o Yes
o No
o Undetermined
o Declined

•

If yes, did disaster survivor get replacement items from any nonprofit organizations?
o Yes
o No
o Undetermined
o Declined

•

If yes, was disaster survivor able to place/install replacement furniture and appliances in
the home?
o Yes
o No
o Undetermined
o Declined

•

Referral needed?

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o Yes
o No
o Undetermined
o Declined
•

Referral services, note all that apply
o Appliances
o Assistance with install of new or removal of old appliances
o Furniture and appliances – other
o Assistance with FEMA ONA
o Assistance with insurance claim/appeal
o Referral to faith based/community organization for replacement

•

Notes (include any information needed to meet need)

Health Insurance and Access to Health Care Assessment
• Do you have health insurance
o Yes
o No
o Undetermined
o Declined
•

If yes, insurance type?
o Affordable Care Act (ACA)
o Medicare
o Other Public
o State Children's Health Insurance Program (S-Chip)
o Medicaid
o Military Insurance

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o Private
o State Children’s Health Insurance Program S-Chip
•

Was this insurance lost as a result of the disaster?
o Yes
o No
o Undetermined
o Declined

•

Referral Needed?
o Yes
o No
o Undetermined
o Declined

•

Referral Services, note all that apply
o Call 911
o Durable medical equipment (e.g. wheelchair, cane)
o Health – other
o Medical equipment
o Clinic referral
o Emergency medical, health insurance related
o Medical care
o Medication

•

Notes (for example, may include name, types, services, or items needed)

Housing Assessment
• In the disaster, was disaster survivor home damaged or affected?
o Yes

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o No
o Undetermined
o Declined
•

Is the disaster survivor able to access the home?
o Yes
o No
o Undetermined
o Declined

•

Does disaster survivor consider home livable or inhabitable?
o Yes
o No
o Undetermined
o Declined

•

Referral needed?
o Yes
o No
o Undetermined
o Declined

•

Disaster survivor damage rating
o Affected
o Major
o Other
o Destroyed
o Minor
o Undetermined

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o Inaccessible
o No damage
o Declined
•

Was disaster survivor relocated/evacuated?
o Yes
o No
o Undetermined
o Declined

•

If yes, what are disaster survivor’s plans to return home (if possible)

•

Do all of disaster survivor’s utilities work?
o Yes
o No
o Undetermined
o Declined

•

If no, which utilities are not working? Note all that apply
o Electrical power
o Internet access
o Sewer and sanitation
o Fuel oil
o Phone
o Heat
o Gas
o Propane
o Water

•

Details of disaster impacts to home

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•

Pre-disaster housing insurance status
o Disaster survivor does not know insurance status
o Disaster survivor owned home and had homeowner’s insurance
o Disaster survivor was insured but does not have insurance policy information
o Disaster survivor had hazard-specific insurance for disaster type (flood, fire,
earthquake)
o Disaster survivor rented home and had renter’s insurance
o Disaster survivor was uninsured
o Other

•

Referral needed?
o Yes
o No
o Undetermined
o Declined

•

Referral services, note all that apply
o Assistance Housing Reservation
o Emergency housing mass care shelter
o Housing – other
o Other emergency housing
o Tarp/blue room
o Utility, housing
o Debris removal, housing repairs
o FEMA-Transitional Shelter Assistance (TSA)
o FEMA – Other shelter
o FEMA – Direct Housing

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o Muck and Gut, Well Repair
o Storage
o Temporary housing, basic needs water, power heat
o Shelter
•

Notes (include necessary information to meet the need)

Transportation Assessment
• What was the disaster survivor’s primary mode of transportation prior to the disaster
o Privately owned vehicle or motorcycle
o Ride with friends/family
o Public transit
o Walk
o Carshare
o Paratransit
o Bike
o Other
•

If privately owned vehicle/motorcycle, is this method of transportation still working postdisaster?
o Yes
o No
o Undetermined
o Declined

•

Referral needed?
o Yes
o No
o Undetermined

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o Declined
•

Referral Services, note all that apply
o Transit pass
o Gas
o Transportation – other
o Transit tokens
o Transportation

•

Notes (for example: unique transportation needs? Like for medical appts. Vs.
employment? For med appts could be met with Medicaid, for example)

Senior Services Assessment
• Assessment date
•

At the time of the disaster, was anyone in the household living in senior housing, assisted
living, or in a nursing home?
o Yes
o No
o Undetermined
o Declined

•

If yes, was the disaster survivor displaced following the disaster?
o Yes
o No
o Undetermined
o Declined

•

If yes, please explain the circumstances

•

Referral Needed?
o Yes

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o No
o Undetermined
o Declined
•

Referral Services, note all that apply
o Assistance with accessing Veterans Affairs (VA) benefits
o Home delivered meals (e.g. Meals on Wheels)
o Referral to area agency on aging
o Assistance with the Low Income Home Energy Assistance Program (LIHEAP)
application
o Referral to Adult Day Health Care Center
o Referral to senior center

•

Notes (information necessary to meet the need)

Legal Services Assessment
• Assessment Date
•

Referral Needed?
o Yes
o No
o Undetermined
o Declined

•

Referral Services, note all that apply
o Other legal service
o Referral to FEMA Disaster Legal Services program
o Referral to Legal Aid

•

Notes (information necessary to meet the need)

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Referrals
Behavioral Health Referral
• Referral Service
o Behavioral Health – Other
o Crisis Counseling Program
o Community clinical provider
o Disaster Distress Helpline
o Counseling Services
o Private Counsel Directory
•

Target Completion Date

•

Refer to Resource

•

Appointment Date/Time (if case manager is asked to make appointment for survivor)

•

Comment/Date

•

Referral Result
o Referral Result Date
o Result
▪

Information only

▪

Rejected

▪

Remaining Unmet Needs

▪

No show

▪

Unmet-resources not available

Child Referral
• Referral Service
o Case manager advocacy
o Referral to early education

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o Referral to social services
o Child-other
o Referral to childcare and referral agency
o Referral to VOAD/community group for education supplies
o Childcare
o Referral to disaster distress helpline
o School district
•

Target completion date

•

Refer to Resource

•

Appointment Date/Time (if case manager is asked to make appointment for survivor)

•

Comment/Date

•

Referral Result
o Referral Result Date
o Result
▪

Information only

▪

Rejected

▪

Met-service rendered

▪

Unmet

▪

No show

▪

Service provided

▪

Met-uninterested/refused

▪

Unmet-resources not available

FEMA/SBA Referral
• Referral Service
o Assist with appeal for SBA denial

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o Assist with completion of FEMA ONA Application
o Assist with FEMA IA denial
o Case Manager Assistance
o Obtain signed FEMA disclosure release from Disaster Survivor
o Submit inquiry to FEMA IA Branch re: Disaster Survivor’s IA
o Assist with completion of FEMA IA application
o Assist with completion of SBA Loan Application
o Assist with FEMA/SBA Sequence of Delivery
o FEMA – Other
o Provide education regarding FEMA/SBA Sequence of Delivery
o Submit inquiry to FEMA IA Branch re: disaster survivor’s ONA
•

Target Completion Date

•

Refer to Resource (write here)

•

Appointment Date/Time (if case manager is asked to make appointment for survivor)

•

Comment/Date

•

Referral Result
o Referral Result Date
o Result
▪

Information only

▪

Rejected

▪

Met - services rendered

▪

Unmet

▪

No show

▪

Service provided

▪

Met- uninterested/refused

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▪

Unmet-resources not available

Clothing Referral
• Referral service
o Assistance with FEMA ONA
o Clothing – other
o Laundry assistance
o Voucher
o Assistance with insurance claim/appeal
o Clothing and other personal items
o Referral to faith-based/community organization for clothing
•

Target completion date

•

Refer to resource (write here)

•

Appointment Date/Time (if case manager is asked to make appointment for survivor)

•

Comment/Date

•

Referral result
o Referral Result Date
o Result
▪

Information only

▪

Rejected

▪

Met-service rendered

▪

Unmet

▪

No show

▪

Service provided

▪

Met- uninterested/refused

▪

Unmet-resources not available

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Employment Referral
• Referral Service
o Education
o Employment placement service
o Employment – other
o Job hunting resources
•

Target completion date

•

Refer to resource (write here)

•

Appointment Date/Time (if case manager is asked to make appointment for survivor)

•

Comment/Date

•

Referral result
o Referral Result Date
o Result
▪

Information only

▪

Rejected

▪

Met-service rendered

▪

Unmet

▪

No show

▪

Service provided

▪

Met- uninterested/refused

▪

Unmet-resources not available

Financial Referral
• Referral service
o FEMA Disaster Unemployment Assistance

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o Grant assistance
o Financial – other
•

Target completion date

•

Refer to resource (write here)

•

Appointment Date/Time (if case manager is asked to make appointment for survivor)

•

Comment/Date

•

Referral result
o Referral Result Date
o Result
▪

Information only

▪

Rejected

▪

Met-service rendered

▪

Unmet

▪

No show

▪

Service provided

▪

Met- uninterested/refused

▪

Unmet-resources not available

Food Referral
• Referral Service
o Assistance with D-SNAP application
o Food bank/pantry
o Referral to community organizations for food needs
o Referred to Senior Meals on Wheels Services
o Food – other
o Food delivery services

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o Referral to mass care assistance for immediate food needs
o Social services for WIC/SNAP/D-SNAP
•

Target completion date

•

Refer to resource (write here)

•

Appointment Date/Time (if case manager is asked to make appointment for survivor)

•

Comment/Date

•

Referral result
o Referral Result Date
o Result
▪

Information only

▪

Rejected

▪

Met-service rendered

▪

Unmet

▪

No show

▪

Service provided

▪

Met- uninterested/refused

▪

Unmet-resources not available

Furniture and Appliances Referral
• Referral Service
o Appliances
o Assistance with install of new or removal of old appliances
o Furniture and appliances – other
o Assistance with FEMA ONA
o Assistance with insurance claim/appeal
o Referral to faith-based/community organization for replacement

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•

Target completion date

•

Refer to resource (write here)

•

Appointment Date/Time (if case manager is asked to make appointment for survivor)

•

Comment/Date

•

Referral result
o Referral Result Date
o Result
▪

Information only

▪

Rejected

▪

Met-service rendered

▪

Unmet

▪

No show

▪

Service provided

▪

Met- uninterested/refused

▪

Unmet-resources not available

Health Referral
• Referral Service
o Call 911
o Durable medical equipment (e.g. wheelchair, cane)
o Health – other
o Medical equipment
o Clinic referral
o Emergency medical, health insurance related
o Medical care
o Medication

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•

Target completion date

•

Refer to resource (write here)

•

Appointment Date/Time (if case manager is asked to make appointment for survivor)

•

Comment/Date

•

Referral result
o Referral Result Date
o Result
▪

Information only

▪

Rejected

▪

Met-service rendered

▪

Unmet

▪

No show

▪

Service provided

▪

Met- uninterested/refused

▪

Unmet-resources not available

Housing Referral
• Referral service
o Assistance Housing Reservation (ARC)
o Emergency housing mass care shelter
o Housing – other
o Other emergency housing
o Tarp/blue roof
o Utility, housing
o Debris removal, housing repairs
o FEMA – Transitional Shelter Assistance (TSA)

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o FEMA – Other shelter
o FEMA – Direct Housing
o Muck and gut, well repair
o Storage
o Temporary housing, basic needs water, power heat
•

Target completion date

•

Refer to resource (write here)

•

Appointment Date/Time (if case manager is asked to make appointment for survivor)

•

Comment/Date

•

Referral result
o Referral Result Date
o Result
▪

Information only

▪

Rejected

▪

Met-service rendered

▪

Unmet

▪

No show

▪

Service provided

▪

Met- uninterested/refused

▪

Unmet-resources not available

Transportation Referral
• Referral service
o Bus pass
o Gas
o Transportation – other

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o Bus tokens
o Transportation
•

Target completion date

•

Refer to resource (write here)

•

Appointment Date/Time (if case manager is asked to make appointment for survivor)

•

Comment/Date

•

Referral result
o Referral Result Date
o Result
▪

Information only

▪

Rejected

▪

Met-service rendered

▪

Unmet

▪

No show

▪

Service provided

▪

Met- uninterested/refused

▪

Unmet-resources not available

Senior Services Referral
• Referral service
o Assistance with accessing VA benefits
o Home delivered meals (e.g. Meals on Wheels)
o Referral to area agency on aging
o Assistance with LIHEAP application
o Referral to Adult Day Health Care Center
o Referral to senior center

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•

Target completion date

•

Refer to resource (write here)

•

Appointment Date/Time (if case manager is asked to make appointment for survivor)

•

Comment/Date

•

Referral result
o Referral Result Date
o Result
▪

Information only

▪

Rejected

▪

Met-service rendered

▪

Unmet

▪

No show

▪

Service provided

▪

Met- uninterested/refused

▪

Unmet-resources not available

Legal Services Referral
• Referral Service
o Other legal service
o Referral to legal aid
o Referral to FEMA Disaster Legal Services program
•

Target completion date

•

Refer to resources (write here)

•

Appointment Date/Time (if case manager is asked to make appointment for survivor)

•

Comment/Date

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•

Referral result
o Referral Result Date
o Result
▪

Information only

▪

Rejected

▪

Met-service rendered

▪

Unmet

▪

No show

▪

Service provided

▪

Met- uninterested/refused

▪

Unmet-resources not available

Record Notes
• Entry date
•

Purpose
o General note
o FEMA Tier Change
o Close Record

•

Notes (information associated with the purpose)

Recovery Plan
• Name
•

Address

•

Email

•

Phone numbers

•

FEMA Registration #

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•

Case Management Worker

•

DR – Disaster Declaration

•

Disaster Survivor ID

•

CM Phone #

•

Disaster Survivor Plan Creation Date

•

Case Manager Site Address

•

FEMA-Administered DCM Worker Signature
o Date and time

•

Disaster Survivor Signature
o Date and time