Privacy Impact Assessment Form

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Privacy Impact Assessment Form
v 1.21
Status

Form Number

Form Date

Question

Answer

1

OPDIV:

CDC/NCHHSTP/DSTDP/SB

2

PIA Unique Identifier:

0920-1072

2a Name:

Enhanced STD Surveillance Network (eSSuN)
General Support System (GSS)
Major Application

3

The subject of this PIA is which of the following?

Minor Application (stand-alone)
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)?

No
Yes
No
Agency
Contractor
POC Title

Project Officer

POC Name

Eloisa Llata, MD, MPH

POC Organization NCHHSTP/DSTDP/SB
POC Email

[email protected]

POC Phone

404-639-6183
New
Existing
Yes
No

8b Planned Date of Security Authorization
Not Applicable

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8c

9

Briefly explain why security authorization is not
required

Indicate the following reason(s) for updating this PIA.
Choose from the following options.

Enhanced SSuN is a surveillance project that does not involve
the creation of any electronic applications or utilize any webbased software. Datasets are created locally as individual SAS
files and securely transmitted to Division of STD
Prevention(DSTDP) with access permissions limited to project
officers and 2 data management stewards. Datasets are
aggregated in SAS for analysis.
PIA Validation (PIA
Refresh/Annual Review)
Anonymous to NonAnonymous
New Public Access
Internal Flow or Collection

Significant System
Management Change
Alteration in Character of
Data
New Interagency Uses
Conversion

Commercial Sources
Renewal of existing OMB (0920-1072) eSSuN

10

Describe in further detail any changes to the system
that have occurred since the last PIA.

11 Describe the purpose of the system.

We are only proposing minor changes to our project (to collect
clinical screening information from additional patients with
primary/secondary syphilis specifically to assess incidence of
neuro/ocular syphilis) but no changes in PII collected, methods
or data management processes.
Enhanced STD Surveillance Network (eSSuN) is designed to
provide critical clinical, demographic and behavioral
information through enhanced and sentinel surveillance
among people diagnosed with gonorrhea, early syphilis with
ocular/neurologic involvement and those persons seeking care
at STD clinics. The objectives of eSSuN are to : 1) assess the
prevalence and trends in risk behaviors among persons
diagnosed with gonorrhea, 2) enhance STD surveillance data,
and inform a more comprehensive understanding of
epidemiologic trends and determinants of STDs of interest, 3)
monitor public health program impact and provide a more
robust evidence-base for directing public health action, and 4)
respond to emerging trends in STDs and related behaviors.

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The Enhanced STD surveillance network awardee's routinely
collect PII for the purpose of monitoring persons seeking STD
clinic services and contacting individuals with gonorrhea and/
or primary & secondary syphilis wtih neuro/ocular
manifestations who agree to participate. The information
collected at the local/state health department level will
include: name, address information, telephone number, date of
birth, gender, race/ethnicity, HIV status, sexual behavior,
insurance status and type, and medical information such as
pre-exposure prophylaxis (PrEP); antiretroviral (ARV) usage,
Describe the type of information the system will
condom usage, and frequency of HIV/STD testing. However,
collect, maintain (store), or share. (Subsequent
neither names, contact information (eg. address, phone
12
questions will identify if this information is PII and ask numbers) or date of birth will be provided to CDC; this
about the specific data elements.)
information will be removed from records prior to being
transmitted to CDC as an encrypted file. CDC will only receive
and maintain patient age, gender race/ethnicity and
nationality. A unique non-identifiable project identification
number is assigned to each case.
The key to link data will only be available at the local level.

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?

The Enhanced STD surveillance network utilizes two distinct
surveillance strategies to collect information. The first is
facility-based STD surveillance which includes abstracting data
in a standardized way from each of the 10 sentinel surveillance
sites from existing electronic medical records for all patient
visits to participating STD clinics during the 3 year OMB time
period. The second strategy is population-based STD
surveillance where a random sample of reported gonorrhea
cases from the total number of gonorrhea case reports
received by each jurisdiction are selected and interviewed.
Additional information are obtained from passive provider
reporting and/or health department record review on the
sampled cases including verification of treatment under their
local regulatory authority to conduct disease surveillance.
Data collected across both strategies include demographicage, race and gender; behavioral and clinical informationclinic/facility name, medical diagnosis, such as treatment.
CDC will only receive and maintain patient age, gender race/
ethnicity and nationality. A unique non-identifiable project
identification number is assigned to each case.
The key to link data will only be available at the local level.
Yes
No

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Indicate the type of PII that the system will collect or
15
maintain.

Social Security Number

Date of Birth

Name

Photographic Identifiers

Driver's License Number

Biometric Identifiers

Mother's Maiden Name

Vehicle Identifiers

E-Mail Address

Mailing Address

Phone Numbers

Medical Records Number

Medical Notes

Financial Account Info

Certificates

Legal Documents

Education Records

Device Identifiers

Military Status

Employment Status

Foreign Activities

Passport Number

Taxpayer ID

Other...

Other...

Other...

Other...

Other...

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)

100,000-999,999
PII is only collected pursuant to local legal authority for disease
surveillance and used only at the local level to complete case
investigations.
There are no secondary uses.

20 Describe the function of the SSN.

Not applicable- SSN is not collected.

20a Cite the legal authority to use the SSN.

Not applicable-SSN is not collected.

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

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

Yes
No

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Published:
Identify the number and title of the Privacy Act
System of Records Notice (SORN) that is being used
22a
to cover the system or identify if a SORN is being
developed.

09-20-0136, “Epidemiologic Studies and Surveilla

Published:
Published:
In Progress
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.

0920-1072; expiration 6/30/2018
Yes

24 Is the PII shared with other organizations?

No
Within HHS
Other Federal
Agency/Agencies
State or Local
Agency/Agencies

Identify with whom the PII is shared or disclosed and
24a
for what purpose.

Private Sector
Describe any agreements in place that authorizes the
information sharing or disclosure (e.g. Computer
24b Matching Agreement, Memorandum of
Not applicable
Understanding (MOU), or Information Sharing
Agreement (ISA)).
24c

Describe the procedures for accounting for
disclosures

Not applicable

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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?

Project participants are informed that their personal
information will be collected prior to their volunteering to
participate in the project.
Voluntary
Mandatory

Describe the method for individuals to opt-out of the
collection or use of their PII. If there is no option to
Individuals have the option to decline to answer any of the
27
object to the information collection, provide a
interview questions or to participate in the project all together.
reason.
Describe the process to notify and obtain consent
from the individuals whose PII is in the system when
major changes occur to the system (e.g., disclosure
28 and/or data uses have changed since the notice at
the time of original collection). Alternatively, describe
why they cannot be notified or have their consent
obtained.

There are no major changes planned for this project. In the
event of major changes, the individual project sites have
contact information available to notify participants and obtain
additional consent if the need arises.

Individuals should reasonably identify the record and specify
the information being contested, the corrective action sought,
and the reasons for requesting the correction, along with
supporting information to show how the record is inaccurate,
incomplete, untimely, or irrelevant. In the event of a suspected
Describe the process in place to resolve an
individual's concerns when they believe their PII has data breach, the reporting jurisdiction must report the incident
29 been inappropriately obtained, used, or disclosed, or with complete information detailing the nature of the
that the PII is inaccurate. If no process exists, explain suspected breach to the CDC Project Officer who reports the
suspected incident to NCHHSTP's Information Security Office
why not.
and works with the individual jurisdiction until the matter has
been resolved. If, however, the individual believes their PII is
inaccurate, this should be reported to the local jurisdiction for
further investigation. CDC does not receive or have access to
the individual'`s PII.

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.

Data collection requirements as a whole are reviewed by CDC
and CDC-funded awardees annually. All PII data is maintained
at the local level and not shared with CDC. Review processes
may vary as each health department will have jurisdictionspecific guidelines in place for conducting internal reviews of
PII in the system. They follow their local data destruction
policies regarding any data they may have collected in
addition to the final dataset in the course of their routine
surveillance activities. They also follow their local policies and
procedures for conducting routine reviews of the data to
ensure availability, integrity, and access to the data. Accuracy is
assured by CDC when they receive the data. CDC receives a
final national dataset and maintains these annual datasets on
secure data drives at CDC. Annual reviews are conducted to
control access and availability of the data to CDC staff. Integrity
is ensured by CDC’s routine back-ups.

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Users

CDC project officers and data stewards
have access to limited PII (e.g., race/

Administrators
31

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

Developers
Contractors

State health department staff
collecting the data for eSSuN. The
Access to PII is based on specific staff role (recruitment,
Describe the procedures in place to determine which retention, study coordination) based on the established
32 system users (administrators, developers,
operational protocol for the surveillance project. CDC never
contractors, etc.) may access PII.
has access to the system that is based and managed locally at
the state/local health departments for all project sites.
Others

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.

Enhanced SSuN collection staff at the state/local health
departments retrieve only the minimum amount of
information required for follow-up data collection for persons
who agreed/consented to participate in the interview. Only the
project coordination and interviewer and/or network
administrators have access to the system containing PII.

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 CDC personnel with data access have completed, and will
remain current with, the annual Information Security and
Privacy Awareness Training.

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

All local and federal staff with access to eSSuN data receive
additional annual security and confidentiality training in
accordance with the National Center for HIV/AIDS, viral
Hepatitis, STDs, and Tuberculosis Prevention’s Data Security
and Confidentiality Guidelines for HIV, Viral Hepatitis, Sexually
Transmitted Disease, and Tuberculosis Programs: Standards to
Facilitate Sharing and Use of Surveillance Data for Public
Health Action. Federal staff’s training is audited annually by a
review of the signed confidentiality training forms. Anyone
without a signed form will have their access to the data
systems terminated.

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 Records Control Schedule 04-4-44c, STD Surveillance
Reports, and annual reports. Record copy of study reports are
maintained in agency records from two to three years in
accordance with retention schedules. Source documents for
computer are disposed of when no longer needed by program
officials. Personal identifiers may be deleted from records
when no longer needed in the study as determined by the
system manager, and as provided in the signed consent form,
as appropriate. Disposal methods include erasing computer
disks or tapes, burning or shredding paper materials or
transferring records to the Federal Records Center when 5
years old and offer to NARA when 20 years old.

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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.

The enhanced SSuN awardee's are responsible for following
their organizations specific security procedures, which at a
minimum include restricting access to the PII to only
authorized users. Staff must gain access to the building
through a keycard. Authentication for access to the network
requires user-id and password. Surveillance data is secured on
a network drive protected by a firewall and requiring special
access permission for staff through IT health departments.

REVIEWER QUESTIONS: The following section contains Reviewer Questions which are not to be filled out unless the user is an OPDIV
Senior Officer for Privacy.

Reviewer Questions
1

Are the questions on the PIA answered correctly, accurately, and completely?

Answer
Yes
No

Reviewer
Notes
2

Does the PIA appropriately communicate the purpose of PII in the system and is the purpose
justified by appropriate legal authorities?

Yes

Do system owners demonstrate appropriate understanding of the impact of the PII in the
system and provide sufficient oversight to employees and contractors?

Yes

No

Reviewer
Notes
3

No

Reviewer
Notes
4

Does the PIA appropriately describe the PII quality and integrity of the data?

Yes
No

Reviewer
Notes
5

Is this a candidate for PII minimization?

Yes
No

Reviewer
Notes
6

Does the PIA accurately identify data retention procedures and records retention schedules?

Yes
No

Reviewer
Notes
7

Are the individuals whose PII is in the system provided appropriate participation?

Yes
No

Reviewer
Notes
8

Does the PIA raise any concerns about the security of the PII?

Yes
No

Reviewer
Notes

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Reviewer Questions
9

Answer

Is applicability of the Privacy Act captured correctly and is a SORN published or does it need
to be?

Yes
No

Reviewer
Notes
10

Is the PII appropriately limited for use internally and with third parties?

Yes
No

Reviewer
Notes
11

Does the PIA demonstrate compliance with all Web privacy requirements?

Yes
No

Reviewer
Notes
12

Were any changes made to the system because of the completion of this PIA?

Yes
No

Reviewer
Notes

General Comments

OPDIV Senior Official
for Privacy Signature

Beverly E.
Walker -S

Digitally signed by
Beverly E. Walker -S
Date: 2018.03.15
18:48:46 -04'00'

HHS Senior
Agency Official
for Privacy

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