Appendix_X_-_Vendor_Name_System_Model_PIA_-_dd2930.pdf

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PIA Template Cereda Amos 20080904 20080904 DoD PIA Template

DD FORM 2930 NOV 2008

Page of

PRIVACY IMPACT ASSESSMENT (PIA)

For the

SECTION 1: IS A PIA REQUIRED?

a. Will this Department of Defense (DoD) information system or electronic collection of information (referred to as an "electronic collection" for the purpose of this form) collect, maintain, use, and/or disseminate PII about members of the public, Federal personnel, contractors or foreign nationals employed at U.S. military facilities internationally? Choose one option from the choices below. (Choose (3) for foreign nationals).

* "Federal personnel" are referred to in the DoD IT Portfolio Repository (DITPR) as "Federal employees."

b. If "No," ensure that DITPR or the authoritative database that updates DITPR is annotated for the reason(s) why a PIA is not required. If the DoD information system or electronic collection is not in DITPR, ensure that the reason(s) are recorded in appropriate documentation.

c. If "Yes," then a PIA is required. Proceed to Section 2.

SECTION 2: PIA SUMMARY INFORMATION

a. Why is this PIA being created or updated? Choose one:

b. Is this DoD information system registered in the DITPR or the DoD Secret Internet Protocol Router Network (SIPRNET) IT Registry?

Please provide this number

c. Does this DoD information system have an IT investment Unique Project Identifier (UPI), required by section 53 of Office of Management and Budget (OMB) Circular A-11?

If unsure, consult the Component IT Budget Point of Contact to obtain the UPI.

Enter if Applicable and known

d. Does this DoD information system or electronic collection require a Privacy Act System of Records Notice (SORN)?

Find at : www.defenselink.mil/privacy/notices A Privacy Act SORN is required if the information system or electronic collection contains information about U.S. citizens or lawful permanent U.S. residents that is retrieved by name or other unique identifier. PIA and Privacy Act SORN information should be consistent.

DoD Component-assigned designator, not the Federal Register number.

Consult the Component Privacy Office for additional information or access DoD Privacy Act SORNs at: http://www.defenselink.mil/privacy/notices/ or

e. Does this DoD information system or electronic collection have an OMB Control Number? Contact the Component Information Management Control Officer or DoD Clearance Officer for this information.

This number indicates OMB approval to collect data from 10 or more members of the public in a 12-month period regardless of form or format.

f. Authority to collect information. A Federal law, Executive Order of the President (EO), or DoD requirement must authorize the collection and maintenance of a system of records.

(1) If this system has a Privacy Act SORN, the authorities in this PIA and the existing Privacy Act SORN should be the same.

(2) Cite the authority for this DoD information system or electronic collection to collect, use, maintain and/or disseminate PII. (If multiple authorities are cited, provide all that apply.)

(a) Whenever possible, cite the specific provisions of the statute and/or EO that authorizes the operation of the system and the collection of PII.

(b) If a specific statute or EO does not exist, determine if an indirect statutory authority can be cited. An indirect authority may be cited if the authority requires the operation or administration of a program, the execution of which will require the collection and maintenance of a system of records.

(c) DoD Components can use their general statutory grants of authority (“internal housekeeping”) as the primary authority. The requirement, directive, or instruction implementing the statute within the DoD Component should be identified.

g. Summary of DoD information system or electronic collection. Answers to these questions should be consistent with security guidelines for release of information to the public.

(1) Describe the purpose of this DoD information system or electronic collection and briefly describe the types of personal information about individuals collected in the system.

(2) Briefly describe the privacy risks associated with the PII collected and how these risks are addressed to safeguard privacy.

h. With whom will the PII be shared through data exchange, both within your DoD Component and outside your Component (e.g., other DoD Components, Federal Agencies)? Indicate all that apply.

i. Do individuals have the opportunity to object to the collection of their PII?

(1) If "Yes," describe method by which individuals can object to the collection of PII.

(2) If "No," state the reason why individuals cannot object.

j. Do individuals have the opportunity to consent to the specific uses of their PII?

(1) If "Yes," describe the method by which individuals can give or withhold their consent.

(2) If "No," state the reason why individuals cannot give or withhold their consent.

k. What information is provided to an individual when asked to provide PII data? Indicate all that apply.

NOTE:

Sections 1 and 2 above are to be posted to the Component's Web site. Posting of these Sections indicates that the PIA has been reviewed to ensure that appropriate safeguards are in place to protect privacy.

A Component may restrict the publication of Sections 1 and/or 2 if they contain information that would reveal sensitive information or raise security concerns.

SECTION 3: PIA QUESTIONNAIRE and RISK REVIEW

a. For the questions in subparagraphs 3.a.(1) through 3.a.(5), indicate what PII (a data element alone or in combination that can uniquely identify an individual) will be collected and describe the source, collection method, purpose, and intended use of the PII.

(1) What PII will be collected? Indicate all individual PII or PII groupings that apply below.

(2) What is the source for the PII collected (e.g., individual, existing DoD information systems, other Federal information systems or databases, commercial systems)?

(3) How will the information be collected? Indicate all that apply.

(4) Why are you collecting the PII selected (e.g., verification, identification, authentication, data matching)?

(5) What is the intended use of the PII collected (e.g., mission-related use, administrative use)?

b. Does this DoD information system or electronic collection create or derive new PII about individuals through data aggregation? (See Appendix for data aggregation definition.)

If "Yes," explain what risks are introduced by this data aggregation and how this risk is mitigated.

c. Who has or will have access to PII in this DoD information system or electronic collection? Indicate all that apply.

d. How will the PII be secured?

(1) Physical controls. Indicate all that apply.

(2) Technical Controls. Indicate all that apply.

(3) Administrative Controls. Indicate all that apply.

e. Does this DoD information system require certification and accreditation under the DoD Information Assurance Certification and Accreditation Process (DIACAP)?

f. How do information handling practices at each stage of the "information life cycle" (i.e., collection, use, retention, processing, disclosure and destruction) affect individuals' privacy?

g. For existing DoD information systems or electronic collections, what measures have been put in place to address identified privacy risks?

h. For new DoD information systems or electronic collections, what measures are planned for implementation to address identified privacy risks?

SECTION 4: REVIEW AND APPROVAL SIGNATURES

Prior to the submission of the PIA for review and approval, the PIA must be coordinated by the Program Manager or designee through the Information Assurance Manager and Privacy Representative at the local level.

Publishing:

Only Sections 1 and 2 of this PIA will be published. Each DoD Component will maintain a central repository of PIAs on the Component's public Web site. DoD Components will submit an electronic copy of each approved PIA to the DoD CIO at: pia@osd.mil.

If the PIA document contains information that would reveal sensitive information or raise security concerns, the DoD Component may restrict the publication of the assessment to include Sections 1 and 2.

APPENDIX

Data Aggregation. Any process in which information is gathered and expressed in a summary form for purposes such as statistical analysis. A common aggregation purpose is to compile information about particular groups based on specific variables such as age, profession, or income.

DoD Information System. A set of information resources organized for the collection, storage, processing, maintenance, use, sharing, dissemination, disposition, display, or transmission of information. Includes automated information system (AIS) applications, enclaves, outsourced information technology (IT)-based processes and platform IT interconnections.

Electronic Collection. Any collection of information enabled by IT.

Federal Personnel. Officers and employees of the Government of the United States, members of the uniformed services (including members of the Reserve Components), and individuals entitled to receive immediate or deferred retirement benefits under any retirement program of the United States (including survivor benefits). For the purposes of PIAs, DoD dependents are considered members of the general public.

Personally Identifiable Information (PII). Information about an individual that identifies, links, relates or is unique to, or describes him or her (e.g., a social security number; age; marital status; race; salary; home telephone number; other demographic, biometric, personnel, medical, and financial information). Also, information that can be used to distinguish or trace an individual's identity, such as his or her name; social security number; date and place of birth; mother's maiden name; and biometric records, including any other personal information that is linked or linkable to a specified individual.

Privacy Act Statements. When an individual is requested to furnish personal information about himself or herself for inclusion in a system of records, providing a Privacy Act statement is required to enable the individual to make an informed decision whether to provide the information requested.

Privacy Advisory. A notification informing an individual as to why information is being solicited and how such information will be used. If PII is solicited by a DoD Web site (e.g., collected as part of an email feedback/comments feature on a Web site) and the information is not maintained in a Privacy Act system of records, the solicitation of such information triggers the requirement for a privacy advisory (PA).

System of Records Notice (SORN). Public notice of the existence and character of a group of records under the control of any agency from which information is retrieved by the name of the individual or by some identifying number, symbol, or other identifying particular assigned to the individual. The Privacy Act of 1974 requires this notice to be published in the Federal Register upon establishment or substantive revision of the system, and establishes what information about the system must be included.

5 U.S.C. 301, Departmental Regulations; 10 U.S.C. Chapter 55, Sections 1071-1097b, Medical and Dental Care; 42 U.S.C. Chapter 117, Sections 11131-11152, Reporting of Information; DoD 6025.18-R, DoD Health Information Privacy Regulation; DoD 6010.8-R, CHAMPUS; DoD Instruction 6015.23, Delivery of Healthcare at Military Treatment Facilities: Foreign Service Care; Third-Party Collection; Beneficiary Counseling and Assistance Coordinators (BCACs); Pub.L. 104-91, Health Insurance Portability and Accountability Act of 1996; and E.O. 9397 (SSN), as amended.

ActivityPurposeExplanation: ***********ENSURE DESCRIPTION PERTAINS TO THIS SYSTEM ******** This is an x-ray diagnostic imaging system, which is used to create a patient image, present the image for diagnostic purposes, and/or transmit the image to a storage device, remote reading workstation or filming device. The image is associated with a particular patient via patient name and a case number.

OverviewDescription: **************PROVIDE SPECIC INFORMATION THAT PERTAINS TO THIS SYSTEM IN THE BOTTOM PARAGRAPH******************

The privacy risks associated with the personally identifiable information (PII)/protected health information (PHI) collected are due to sharing, using, and viewing PII/PHI. However, all applicable security and privacy processes and regulations have been defined and implemented, reducing risks and safeguarding privacy.

PHI is aggregated through the DICOM Modality Worklist from a DIACAP accredited PACS and displayed on the system during treatment.

The MTFs computer facilities housing the system have physical, technical, and administrative controls created in accordance with local policies such as office door locks, monitoring by facility staff, and application timeouts. Safeguards include techniques deployed on the system itself, including password protection, and where applicable, encryption techniques. Software installation includes security patch installation current at the time of that software release.

processes contain patient admission forms that include detailed PII/PHI discussion. By agreeing to an appointment or treatment/procedure, the individual is providing implied consent. Under the HIPAA Privacy Rule certain information is required in the course of treating the patient, in order to identify the patient and document treatment. The HIPAA privacy rules do not require that a patient have an opportunity to object to or consent to the use of their information for treatment, payment, or health care operations. Treatment is not subject to the minimum necessary rules. Conversely, the HIPAA Notice of Privacy Practices, which is available to all patients and posted in the MTF, describes the uses and disclosures of protected health information and how, where applicable, a patient can request a restriction to a use or disclosure. However, the covered entity is not required to agree to the restriction, except in limited circumstances.

PII is collected by a System to System transfer. Using an existing DoD Information System: through DICOM Modality Worklist from an accredited PACS which obtains the original PII from CHCS. The current accredited PACS include the following: McKesson Radiology PACS, Fuji Synapse, ScImage PICOM, and AGFA Impax.

OR

For Modalities, which are "the Acquisition System XXX" (e.g. CTs, MRIs, CRs); The source for the PII will be collected from an existing accredited Hospital Information system or Health Record system within the DoD. The patient demographics data is collected and feeds the information to an accredited Picture Archiving Communication System (PACS) system. The "Acquisition System XXX" will query the Digital Communication in Medicine (DICOM) modality worklist for the patient data from the accredited PACS.

Handling Practices: To minimize exposure the existing collection system is certified and accredited to ensure confidentiality and information handling practice are adequate.

Use, Retention, and Processing: Only personnel with the “need to know” can access a member’s PII information. Transmission and storage are encrypted or otherwise protected.

Disclosure: No other personnel other than those with a “need to know” can access a member’s PII information unless permission is granted from the individual in writing to release the information.

Destruction: Data is destroyed in accordance with the AF Records Management Manual.