HAIC MuGSI PIA

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Privacy Impact Assessment Form
v 1.47.4
Status Draft

Form Number

F-48877

Form Date

Question

Answer

1

OPDIV:

CDC

2

PIA Unique Identifier:

P-2825551-916675

2a Name:

1/6/2020 2:31:16 PM

Multi-Site Gram-Negative Bacilli Surveillance Initiative (MuGSI)
General Support System (GSS)
Major Application

3

Minor Application (stand-alone)

The subject of this PIA is which of the following?

Minor Application (child)
Electronic Information Collection
Unknown

3a

Identify the Enterprise Performance Lifecycle Phase
of the system.

Operations and Maintenance
Yes

3b Is this a FISMA-Reportable system?

4

Does the system include a Website or online
application available to and for the use of the general
public?

5

Identify the operator.

6

Point of Contact (POC):

7

Is this a new or existing system?

8

Does the system have Security Authorization (SA)?

8b Planned Date of Security Authorization

No
Yes
No
Agency
Contractor
POC Title

Public Health Advisor

POC Name

Alvin Schultz

POC Organization NCEZID/DPEI
POC Email

[email protected]

POC Phone

404-639-7028
New
Existing
Yes
No
April 2, 2020
Not Applicable

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11 Describe the purpose of the system.
Describe the type of information the system will
collect, maintain (store), or share. (Subsequent
12
questions will identify if this information is PII and ask
about the specific data elements.)
Provide an overview of the system and describe the
13 information it will collect, maintain (store), or share,
either permanently or temporarily.
14 Does the system collect, maintain, use or share PII?

15

Indicate the type of PII that the system will collect or
maintain.

MuGSI is a surveillance initiative designed to evaluate the
population-based incidence of carbapenem-nonsusceptibility
The system collects de-identified patient data (Date of Birth,
Medical Notes, Gender, Race, Ethnicity and County and State of
residence).
MuGSI is a surveillance project designed to evaluate the
population-based incidence of carbapenem-nonsusceptibility
(antibiotic resistance) among common strains of bacteria.
Yes
No
Social Security Number

Date of Birth

Name

Photographic Identifiers

Driver's License Number

Biometric Identifiers

Mother's Maiden Name

Vehicle Identifiers

E-Mail Address

Mailing Address

Phone Numbers

Medical Records Number

Medical Notes

Financial Account Info

Certificates

Legal Documents

Education Records

Device Identifiers

Military Status

Employment Status

Foreign Activities

Passport Number

Taxpayer ID
Gender
State
County
Race
Ethnicity
Employees
Public Citizens
16

Indicate the categories of individuals about whom PII
is collected, maintained or shared.

Business Partners/Contacts (Federal, state, local agencies)
Vendors/Suppliers/Contractors
Patients
Other

17 How many individuals' PII is in the system?

18 For what primary purpose is the PII used?

19

Describe the secondary uses for which the PII will be
used (e.g. testing, training or research)

500-4,999
PII is used to geographically and demographically locate the
incident of disease and categorize it by impacted demographic
groups.
This information will be used for research purposes to better
inform the public on how to prevent and/or treat these
diseases.

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20 Describe the function of the SSN.

N/A

20a Cite the legal authority to use the SSN.

N/A

Public Health Service Act, Section 301, "Research and
Identify legal authorities governing information use Investigation," (42 U.S.C. 241); and Sections 304, 306 and 308(d)
21
which discuss authority to maintain data and provide
and disclosure specific to the system and program.
assurances of confidentiality for health research and related
activities (42 U.S.C. 242 b, k, and m(d)).
22

Yes

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

No
Directly from an individual about whom the
information pertains
In-Person
Hard Copy: Mail/Fax
Email
Online
Other
Government Sources

23

Within the OPDIV
Other HHS OPDIV
State/Local/Tribal
Foreign
Other Federal Entities
Other

Identify the sources of PII in the system.

Non-Government Sources
Members of the Public
Commercial Data Broker
Public Media/Internet
Private Sector
Other
23a

Identify the OMB information collection approval
number and expiration date.

24 Is the PII shared with other organizations?

0920-0978 12/17/2020
Yes
No

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Within HHS

24a

Identify with whom the PII is shared or disclosed and
for what purpose.

Other Federal
Agency/Agencies
State or Local
Agency/Agencies
The information is shared among participating state health
departments who supply data to MuGSI to understand,
where, when and how antibiotic resistant related illnesses
are occuring and to aid in prevention and treatment.
Private Sector

Describe any agreements in place that authorizes the
information sharing or disclosure (e.g. Computer
24b Matching Agreement, Memorandum of
Understanding (MOU), or Information Sharing
Agreement (ISA)).
24c

Describe the procedures for accounting for
disclosures

Describe the process in place to notify individuals
25 that their personal information will be collected. If
no prior notice is given, explain the reason.

26

Is the submission of PII by individuals voluntary or
mandatory?

N/A. No agreement other than CDC rules of behavior. State
partners provide the data to the CDC, and the CDC shares it
back to the participating states in the form of reports the state
partners use for data analysis.
N/A. Not subject to Privacy Act
Prior notice is not given to the individuals because the data is
provided by the State and Local Health Departments, and any
prior notice would be given by theses entities. CDC collects
this data whenever a case antibiotic resistant bacteria is
reported by a partner health agency, as required.
Voluntary
Mandatory

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

There is no option to object to the collection of the
information. Local health regulations require these types of
confirmed laboratory test results to be reported. The
information collected by this system comes from State and
Local Public Health departments whenever a case antibiotic
resistant bacteria is reported by a partner health agency.

Describe the process to notify and obtain consent
from the individuals whose PII is in the system when
major changes occur to the system (e.g., disclosure
28 and/or data uses have changed since the notice at
the time of original collection). Alternatively, describe
why they cannot be notified or have their consent
obtained.

If there were major changes to the system, it would not be
possible to notify and obtain consent from the individuals
whose PII is in the system, because the system does not collect
any identifiable information that would allow CDC to contact
them.

Describe the process in place to resolve an
individual's concerns when they believe their PII has
29 been inappropriately obtained, used, or disclosed, or
that the PII is inaccurate. If no process exists, explain
why not.

There is not a redress process in place because of the nature of
the data that the system maintains; there is no direct identifier
or contact information collected. The individual can, however,
contact the health facility where the PII was collected, and any
redress rights would be exercised at the state and local levels
where the information is collected.

Describe the process in place for periodic reviews of
PII contained in the system to ensure the data's
30
integrity, availability, accuracy and relevancy. If no
processes are in place, explain why not.

The PII will be reviewed by the Multi-Site Gram-Negative Bacilli
Surveillance Initiative change management team using a view
of the Emerging Infections Program Web Service (EWS) web
service repository. EWS provides the PII data to the Multi-Site
Gram-Negative Bacilli Surveillance Initiative. There is a Data
Use Agreement between these two systems.

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Users
Administrators

Identify who will have access to the PII in the system
31
and the reason why they require access.

Developers

Contractors

Administrators have access to PII for
maintenance and support.
Direct contractors have access to PII for
maintenance and support of the
system like system upgrades and bug
fixes.
Direct contractors working as
developers or system administrators
have access to PII for maintenance and
support of the system like system

Others
Describe the procedures in place to determine which The Business Steward determines which system users access
32 system users (administrators, developers,
PII according to their need to administer or correct errors in the
contractors, etc.) may access PII.
system and role based controls are established for these

Describe the methods in place to allow those with
33 access to PII to only access the minimum amount of
information necessary to perform their job.

Least privilege methods are employed to ensure that those
with access to PII can only access the minimum amount
necessary to perform their job.
Ways of creating least privilege include limiting specific users
to only being able to read data, read and enter data, or give
administrators full access to the database.

Identify training and awareness provided to
personnel (system owners, managers, operators,
contractors and/or program managers) using the
34
system to make them aware of their responsibilities
for protecting the information being collected and
maintained.

All personnel annually receive security and privacy awareness
training on an annual basis.

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

System users also receive role based training.

Do contracts include Federal Acquisition Regulation
36 and other appropriate clauses ensuring adherence to
privacy provisions and practices?

Describe the process and guidelines in place with
37 regard to the retention and destruction of PII. Cite
specific records retention schedules.

Yes
No
Records are retained and disposed of in accordance with the
CDC Scientific and Research Project Retention Schedule
N1-442-09-001. Personal identifiers may be deleted from
records when no longer needed in the study as determined by
the system manager, and as provided in the signed consent
form, as appropriate. Disposal methods include erasing
computer tapes, burning or shredding paper materials or
transferring records to the Federal Records Center when no
longer needed for evaluation and analysis.

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Describe, briefly but with specificity, how the PII will
38 be secured in the system using administrative,
technical, and physical controls.

Administrative controls include A data use agreement put in
place between MuGSI and Emerging Infections Program Web
Service Web Service to ensure correct use of information
received. Additionally, both systems will be hosted within the
CDC Application Hosting Branch and under the Standard
operating procedures and security imposed by the CDC.
Technical controls include the implementation of encryption.
Database security is used to allow the MuGSI application
access to the repository to consume the information received
by the web service.
Physical controls included security guards at gate to access
facility, card key access and physical locks to data rooms.

General Comments

OPDIV Senior Official
for Privacy Signature

signed by Jarell
Jarell Oshodi Digitally
Oshodi -S
Date: 2020.03.18 16:13:52
-S
-04'00'

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