1625-0009 Privacy Threshold Analysis (PTA)

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

PRIVACY THRESHOLD ANALYSIS (PTA)
This form serves as the official determination by the DHS Privacy Office to
identify the privacy compliance requirements for all Departmental uses of
personally identifiable information (PII).
A Privacy Threshold Analysis (PTA) serves as the document used to identify
information technology (IT) systems, information collections/forms, technologies,
rulemakings, programs, information sharing arrangements, or pilot projects that involve
PII and other activities that otherwise impact the privacy of individuals as determined by
the Chief Privacy Officer, pursuant to Section 222 of the Homeland Security Act, and to
assess whether there is a need for additional Privacy Compliance Documentation. A PTA
includes a general description of the IT system, information collection, form, technology,
rulemaking, program, pilot project, information sharing arrangement, or other Department
activity and describes what PII is collected (and from whom) and how that information is
used and managed.
Please complete the attached Privacy Threshold Analysis and submit it to your
component Privacy Office. After review by your component Privacy Officer the PTA is sent
to the Department’s Senior Director for Privacy Compliance for action. If you do not have a
component Privacy Office, please send the PTA to the DHS Privacy Office:
Senior Director, Privacy Compliance
The Privacy Office
U.S. Department of Homeland Security
Washington, DC 20528
Tel: 202-343-1717
[email protected]
Upon receipt from your component Privacy Office, the DHS Privacy Office will review this
form and assess whether any privacy compliance documentation is required. If compliance
documentation is required – such as Privacy Impact Assessment (PIA), System of Records
Notice (SORN), Privacy Act Statement, or Computer Matching Agreement (CMA) – the DHS
Privacy Office or component Privacy Office will send you a copy of the relevant compliance
template to complete and return.

Privacy Threshold Analysis – IC/Form

Version number: 04-2016
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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:

CG-4602A

Form Title:

Oil Record Book for Ships

Component:

U.S. Coast Guard (USCG)

Office:

CG-REG

IF COVERED BY THE PAPERWORK REDUCTION ACT:
Collection Title:
Oil Record Book for Ships
OMB Control
Number:
Collection status:

Name:
Office:
Phone:

Name:
Office:
Phone:

1625-0009
Extension

OMB Expiration
Date:
Date of last PTA (if
applicable):

May 31, 2019
Click here to enter
a date.

PROJECT OR PROGRAM MANAGER
Mr. David Du Pont
CG-REG
Title:
Reg Dev Mgr
202-372-1497
Email:
[email protected]
COMPONENT INFORMATION COLLECTION/FORMS CONTACT
Mr. Arthur Requina
CG-612
Title:
Forms Manager
202-475-3651
Email:
[email protected]

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

SPECIFIC IC/Forms PTA QUESTIONS
1. Purpose of the Information Collection or Form
The purpose of the form (CG-4602A) is to aid the Coast Guard in verifying compliance
with the Act to Prevent Pollution from Ships (APPS) and the International Convention for
Prevention of Pollution from Ships, 1973, as modified by the 1978 Protocol relating
thereto (MARPOL 73/78). Title 33 CFR 151.25 requires that information about oil cargo
and fuel operations be entered into the Oil Record Book (form). The Coast Guard
reviews the form during periodic inspections, random boardings, and post-casualty
investigations.
Form CG-4602A contains basic business contact information, which may include the
name and address of the facility and/or vessel, if owned/operated by an individual.
Additionally, the form contains the signatures of individuals responsible for certain
vessel operations as detailed in 33 CFR 151.25.
The authority for this collection is 33 U.S.C. 1901 et seq.

2. Describe the IC/Form
a. Does this form collect any
Personally Identifiable
Information” (PII1)?
b. From which type(s) of
individuals does this form
collect information?
(Check all that apply.)

Yes
☐No
Members of the public
U.S. citizens or lawful permanent
residents
Non-U.S. Persons.
☐DHS Employees
☐DHS Contractors
☐Other federal employees or contractors.

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.
Privacy Threshold Analysis – IC/Form

Version number: 04-2016
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Privacy Office
U.S. Department of Homeland Security
Washington, DC 20528
202-343-1717, [email protected]
www.dhs.gov/privacy

c. Who will complete and
submit this form? (Check
all that apply.)

The record subject of the form (e.g., the
individual applicant).
☐Legal Representative (preparer, attorney, etc.).
Business entity.
If a business entity, is the only
information collected business contact
information?
Yes
☐No
☐Law enforcement.
☐DHS employee or contractor.
☐Other individual/entity/organization that is
NOT the record subject. Please describe.
Click here to enter text.

d. How do individuals
complete the form? Check
all that apply.

Paper.
☐Electronic. (ex: fillable PDF)
☐Online web form. (available and submitted via
the internet)
Provide link:

e. What information will DHS collect on the form? The form contains basic business
contact information, which may include the name and address of the facility
and/or vessel, if owned/operated by an individual. Additionally, the form
contains the signatures of individuals responsible for certain vessel operations as
detailed in 33 CFR 151.25.
f. Does this form collect Social Security number (SSN) or other element that is
stand-alone Sensitive Personally Identifiable Information (SPII)? No.
☐ 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
☐ Passport Number
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Version number: 04-2016
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Privacy Office
U.S. Department of Homeland Security
Washington, DC 20528
202-343-1717, [email protected]
www.dhs.gov/privacy

☐ Bank Account, Credit Card, or other
financial account number
☐ Other. Please list:

☐ Trusted Traveler Number (Global
Entry, Pre-Check, etc.)
☐ Driver’s License Number
☐ Biometrics

g. List the specific authority to collect SSN or these other SPII elements.
N/A
h. How will this information be used? What is the purpose of the collection?
Describe why this collection of SPII is the minimum amount of information
necessary to accomplish the purpose of the program.
N/A
i.

Are individuals
provided notice at the
time of collection by
DHS (Does the records
subject have notice of
the collection or is
form filled out by
third party)?

Yes. Please describe how notice is provided.
A PAS is on the form.
☐No.

3. How will DHS store the IC/form responses?
a. How will DHS store
☐Paper. Please describe.
the original,
Click here to enter text.
completed IC/forms?
☐Electronic. Please describe the IT system that will
store the data from the form.
Click here to enter text.
☐Scanned forms (completed forms are scanned into
an electronic repository). Please describe the
electronic repository.
N/A.

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

b. If electronic, how
does DHS input the
responses into the IT
system?

☐Manually (data elements manually entered). Please
describe.
☐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
Click here to enter text.
forms, i.e., how is the
☐By a non-personal identifier. Please describe.
information
No information is retrieved.
retrieved?
d. What is the records
N/A.
retention
schedule(s)? Include
the records schedule
number.
e. How do you ensure
N/A.
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?
☐Yes, information is shared with other DHS components or offices. Please describe.
Click here to enter text.
☐Yes, information is shared external to DHS with other federal agencies, state/local
partners, international partners, or non-governmental entities. Please describe.
Click here to enter text.
No. Information on this form is not shared outside of the collecting office.

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

Please include a copy of the referenced form and Privacy Act Statement (if
applicable) with this PTA upon submission.

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Version number: 04-2016
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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:

Kenlinishia Tyler

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

April 17, 2019
April 24, 2019
X☐Yes. Please include it with this PTA
submission. A PAS is on the form.
☐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 purpose of the form (CG-4602A) is to aid the Coast Guard in verifying compliance with
the Act to Prevent Pollution from Ships (APPS) and the International Convention for
Prevention of Pollution from Ships, 1973, as modified by the 1978 Protocol relating thereto
(MARPOL 73/78). Title 33 CFR 151.25 requires that information about oil cargo and fuel
operations be entered into the Oil Record Book (form). The Coast Guard reviews the form
during periodic inspections, random boardings, and post-casualty investigations.
Form CG-4602A contains basic business contact information, which may include the name
and address of the facility and/or vessel, if owned/operated by an individual. Additionally,
the form contains the signatures of individuals responsible for certain vessel operations as
detailed in 33 CFR 151.25.
This collection is covered by DHS/USCG/PIA-008 Marine Information for Safety and Law
Enforcement (MISLE) and DHS/USCG-013 Marine Information for Safety and Law
Enforcement (MISLE).
During non-standard practices when periodic inspections, random boardings, and postcasualty investigations occur that could result in an Oil Record Book violation, PII could be
retrieved and thus is also covered under the MISLE PIA and SORN.

Privacy Threshold Analysis – IC/Form

Version number: 04-2016
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Privacy Office
U.S. Department of Homeland Security
Washington, DC 20528
202-343-1717, [email protected]
www.dhs.gov/privacy

This collection is covered by DHS/USCG/PIA-008 Marine Information for Safety and Law
Enforcement (MISLE) and DHS/USCG-013 Marine Information for Safety and Law
Enforcement (MISLE).

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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:

Joseph McCaskill

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

1179998
April 30, 2019
April 30, 2022
Riley Dean

DESIGNATION
Privacy Sensitive IC or
Form:

Yes

If “no” PTA adjudication is complete.

Determination:

☐PTA sufficient at this time.
☐Privacy compliance documentation determination in progress.
☐New information sharing arrangement is required.
☐DHS Policy for Computer-Readable Extracts Containing SPII
applies.
☒ Privacy Act Statement required.
☒ Privacy Impact Assessment (PIA) required.
☒ System of Records Notice (SORN) required.
☐Specialized training required.
☐Other. Click here to enter text.

DHS IC/Forms Review:

Choose an item.

Date IC/Form Approved Click here to enter a date.
by PRIV:
IC/Form PCTS Number: Click here to enter text.
Privacy Act
Privacy Act Statement Required
Statement:

Privacy Threshold Analysis – IC/Form

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

USCG should ensure the Privacy Act Statement on FORM CG-4602A
remains accurate based on this PTA, and contains authority, purpose,
routine uses, and disclosure
PTA:
System PTA Required
PIA:
System covered by existing PTA
If covered by existing PIA, please list: DHS/USCG/PIA-008 Marine
Information for Safety and Law Enforcement (MISLE)
If a PIA update is required, please list:
SORN:
System covered by existing SORN
If covered by existing SORN, please list: DHS/USCG-013 - Marine
Information for Safety and Law Enforcement (MISLE), June 25, 2009 74
FR 30305
If a SORN update is required, please list:
DHS Privacy Office Comments:
Please describe rationale for privacy compliance determination above.
USCG Privacy is submitting this PTA for the renewal of form (CG-4602A) to aid the Coast
Guard in verifying compliance with the Act to Prevent Pollution from Ships (APPS) and the
International Convention for Prevention of Pollution from Ships, 1973, as modified by the
1978 Protocol relating thereto (MARPOL 73/78). Title 33 CFR 151.25 requires that
information about oil cargo and fuel operations be entered into the Oil Record Book (form).
The Coast Guard reviews the form during periodic inspections, random boardings, and
post-casualty investigations. Form CG-4602A contains basic business contact information,
which may include the name and address of the facility and/or vessel, if owned/operated
by an individual. Additionally, the form contains the signatures of individuals responsible
for certain vessel operations as detailed in 33 CFR 151.25. The authority for this collection
is 33 U.S.C. 1901 et seq.
DHS Privacy Office (PRIV) finds the system is privacy sensitive. The collection of business
contact information, and signatures of individuals responsible for certain vessel operations
is covered by DHS/USCG/PIA-008. The retrieval of information by unique identifier during
non-standard practices when periodic inspections, random boardings, and post-casualty
investigations occur that could result in an Oil Record Book violation, PII could be
retrieved, is covered by DHS/USCG-013. This PTA is valid until April 30, 2022.

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