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Att5 Privacy Impact Assessment 2020.pdf

[ATSDR] National Amyotrophic Lateral Sclerosis (ALS) Registry

PIA

OMB: 0923-0041

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Privacy Impact Assessment Form
v 1.47.4
Status Draft

Form Number

F-68239

Form Date

Question

Answer

1

OPDIV:

CDC

2

PIA Unique Identifier:

P-7011560-917071

2a Name:

4/13/2020 9:16:22 AM

Amyotrophic Lateral Sclerosis Web Portal (ALS)
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

Medical Epidemiologist

POC Name

Paul Mehta

POC Organization ATSDR
POC Email

pum4@cdc.gov

POC Phone

770-488-0556
New
Existing
Yes
No
June 18, 2020
Not Applicable

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11 Describe the purpose of the system.

The purpose of the Amyotrophic Lateral Sclerosis (ALS) Web
Portal is to obtain more complete information on the likely
prevalence of ALS ("Lou Gehrig's Disease"), and to better
describe the demographic characteristics (age, race, sex, and
geographic location) of those with ALS. The secondary goal of
the surveillance system is to collect additional information on
potential risk factors for ALS including, but not limited to,
family history of ALS, smoking history, and military service.
These risk factors were chosen because they are the only
known and consistently recognized risk factors for ALS, and we
want to obtain baseline assessment of basic risk factors on the
registry participants. This information could then be used to
design studies about what causes ALS.
The ALS Web Portal will collect, maintain, or share the
following types of information:

Patient Registration (Name, Race, Gender, Date of Birth
[month/year], Email, City, State, Country, Social Security
Number [SSN])
Security Questions (First Car, Favorite Color, First Pet Name,
etc.)
Patient Surveys (Military Status, Health Notes, Employment,
Describe the type of information the system will
Demographics, Work history, Alcohol & Smoking
collect, maintain (store), or share. (Subsequent
12
questions will identify if this information is PII and ask Consumption, Family History, etc.)
Information Requests (Name, Address, Email, Phone Number).
about the specific data elements.)
During patient registration, SSN [last 5 digits] and date of birth
are only stored in the system temporarily and moved to
another server daily. ALS Patients cannot retrieve or view their
SSN after it is collected.
ALS authenticates external (public) users with username (user's
email address) and password which are stored in the system.
Internal users are authenticated via CDC's Active Directory
(AD). AD is a separate system with its own PIA.

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The purpose of the ALS Web Portal is to provide users with
more information regarding the disease and to facilitate
research for medical professionals and individual researchers.
Researchers may request de-identified survey data for their
own research. Identifiable data is shared with external
researchers.
The system collects registration information, surveys, and
security questions from users of the site. These users are
members of the public with ALS and are over 18 years of age.
Registration information is used to uniquely identify
participating individuals in the registry, for account support,
and to contact the patients. Security questions are used if the
patients forget their passwords. Surveys data is used to
identify risk factors for ALS and inform research looking into
the cause(s) of ALS.

Provide an overview of the system and describe the
13 information it will collect, maintain (store), or share,
either permanently or temporarily.

Patient Registration (Name, Race, Gender, Date of Birth
[month/year], Email, City, State, Country, Social Security
Number [SSN])
Security Questions (First Car, Favorite Color, First Pet Name,
etc.)
Patient Surveys (Military Status, Health Notes, Employment,
Demographics, Work history, Alcohol & Smoking
Consumption, Family History, etc.)
Information Requests (Name, Address, Email, Phone Number)
are collected.
The system collects information request data in order to mail
brochures. This data is collected from members of the general
public and is not directed at children.
Data is regularly retrieved from the system using ALS patient
name, email address, or phone number for account
maintenance or user verification. SSN is also used to match
with data in other systems so that ALS patients are not double
counted.
ALS authenticates external (public) users with username and
password which are stored in the system. The username is the
user's email address. Internal user are authenticated via CDC's
Active Directory (AD) AD is a separate system covered by its
own PIA.

14 Does the system collect, maintain, use or share PII?

Yes
No

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15

Indicate the type of PII that the system will collect or
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
Gender
Responses to security questions
User credentials (user name and password)

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)

10,000-49,999
The PII is used to facilitate research for medical professionals
and individual researchers.
The SSN is used as a quality check to prevent the submission of
duplicate records.

20 Describe the function of the SSN.

The Registry is only asking for the last 5 digits of the Social
Security number, not the entire 9 digit number. Because the
Registry identifies cases of ALS from multiple sources,
including from Medicare and the Veterans Administration, the
Registry needs to make sure people are not counted twice.
The only way to be sure that two people with the same or
similar names are not the same person is with a partial Social
Security number.

20a Cite the legal authority to use the SSN.

E.O. 9397, as amended by E.O. 13478.

21

Identify legal authorities governing information use
ALS Registry Act, Public Law No: 110-373
and disclosure specific to the system and program.

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22

Yes

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

No
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.

09-19-0001, Records of Persons Exposed or
Potentially Exposed to Toxic or Hazardous
Substances

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.

24 Is the PII shared with other organizations?
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?

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.

OMB 0923-0041, 01/31/2023
Yes
No
Individuals are notified during the self-registration process
before creating an account, how their data will be used in the
ALS System via a Privacy Notice screen.
Voluntary
Mandatory
There is a customized Consent Form that allows ALS patients
to agree or disagree with CDC/ATSDR’s terms. The decision of
the patient is voluntary and will determine whether or not an
account is created.

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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.

In the event of significant system changes, a modified SORN
would be published in the Federal Register. Further, the
current PIA would be modified and published addressing the
changes and identifying any new, resulting privacy
considerations.

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.

Users can contact ATSDR via the contact information provided
on the ALS website if any issues occur. 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.

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 data is downloaded and cleaned annually. It is reviewed
for accuracy – duplicates are removed, all fields are reviewed
for relevancy and consistency. Statisticians check all data
against these requirements and a “clean” file is produced. This
file then is provided to and independent Statistician for
validation. If any discrepancies are found the data is reviewed
manually and any discrepancies are resolved. If changes or
updates to the database is required those changes are
completed based on the validation process. This cleaned and
validated file is now the official file.
Users
Administrators

31

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

Administrators need access to
maintain data.

Developers
Contractors
Others

Statisticians need access to analyze
data.

Describe the procedures in place to determine which
Role-based access procedures are used to determine who will
32 system users (administrators, developers,
have access to PII in the system.
contractors, etc.) may access PII.

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.

The least privilege method is used to ensure that those with
access to PII are only able to access the minimum amount
necessary to perform their job responsibilities. Examples of
controls that are employed are: (1) SQL read/write permissions
that are controlled by user roles and privileges. (2) Active
Directory controls administrator access. (3) E-Authentication
control for external users.

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.

Personnel are required to undergo Annual Security and Privacy
Awareness Training (SAT).

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

None

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.

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

Yes
No
Records are retained, disposed, stored, handled, and viewed in
accordance with the ATSDR Comprehensive Records Control
Schedule (B-371), GSR 20.2c& d, and GSR 20.6. Current
procedures allow the system manager to keep the records for
20 years unless needed for further study. Registry records will
be actively maintained as long as funding is provided for by
law. Retention periods vary depending on the type of record.
Source documents for computer tapes or disks are securely
disposed of when no longer needed in the study as
determined by the system manager, and as provided in the
signed consent form, as appropriate.
Administrative: Users are assigned unique roles and privileges
depending on their user status. ALS patients are able to create
an “ALS Patient” account, while all other public users are
required to create a “Public” account. The ALS “System
Administrator” can manage patient and public accounts and
download data. ALS Patients must also pass a validation
process before creating an ALS Patient Account. The validation
process is a series of questions that determine if a patient has
ALS. The general public can create a Public account without
going through a validation process.
Technical: PII fields will be masked on the GUI depending on
the sensitivity of the data. For example the last 5 numbers of
the SSN will be masked. All PII including SSN will be encrypted
using CDC approved methods. To encrypt/decrypt data in
database columns designed to hold PII data, a user must be
given access to open and close a symmetric key.
Physical Controls: Production and test servers are stored in a
server room secured by the CDC. Access tools are in place to
secure entry into CDC buildings (Guards, ID Badges, Key Card,
Cipher Locks, and Closed Circuit TV).

39 Identify the publicly-available URL:
40 Does the website have a posted privacy notice?

http://wwwn.cdc.gov/als
Yes
No

40a

Is the privacy policy available in a machine-readable
format?

Yes

41

Does the website use web measurement and
customization technology?

Yes

No
No

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Technologies

Yes

Web beacons

No
Yes

Web bugs
Select the type of website measurement and
41a customization technologies is in use and if it is used
to collect PII. (Select all that apply)

Collects PII?

No

Session Cookies
Persistent Cookies

Yes
No
Yes
No
Yes

Other...

No

42

Does the website have any information or pages
directed at children under the age of thirteen?

Yes

43

Does the website contain links to non- federal
government websites external to HHS?

Yes

No

No

General Comments

OPDIV Senior Official
for Privacy Signature

Beverly E.
Walker -S

Digitally signed by
Beverly E. Walker -S
Date: 2020.06.16 14:46:16
-04'00'

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