Att A-5. PIA Test Predictability of Falls Screening Tool TPFST 3-22-2017 (002)

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Privacy Impact Assessment Form
v 1.47.4
Status Draft

Form Number

F-94855

Form Date

Question

Answer

1

OPDIV:

CDC

2

PIA Unique Identifier:

P-1493325-640424

2a Name:

3/22/2017 8:15:30 AM

Test Predictability of Falls Screening Tool (TPFST)
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.

Design
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

Behavioral Scientist

POC Name

Gwendolyn Bergen

POC Organization CDC/ONDIEH/NCIPC/DUIP
POC Email

gjb8@cdc.gov

POC Phone

770.488.1394
New
Existing
Yes
No
April 20, 2017
Not Applicable

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The Test Predictability of Falls Screening Tool (TPFST) is being
designed as a data repository and management system for the
fall risk screening initiative by CDC/National Center for Injury
Prevention and Control (NCIPC). As such, it will store responses
to the screening questions asked of the study participants s
well as enable the project staff to track the progression of
cases during the project.

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.)

TPFST will facilitate clinicians' ability to identify adults 65 and
older who are likely to fall and thus will need additional,
specialized care in the future. Although there are a number of
tools used to screen older adults for fall risk, there is currently
no standard for fall risk screening across care settings. It is
anticipated that the questions asked and the results identified
via this tool will be recommended for use by CDC as the
standard for screening of falls for adults 65 and older in clinical
settings. Questions will be asked to a nationally representative
sample of adults 65 and older, who will then be followed with
surveys repeated monthly over the following year to
determine whether and how often they fall.

The TPFST will collect and store case-level call history data to
track the status of a screened case, and study participants'
responses to the screening questions. The screening questions
will determine patients' risk levels for falls.
TPFST will collect and store the information obtained as part of
this study, to include both case-level call history data and
participant responses to questionnaires. The call history data
will be stored in the system separately from the questionnaire
data. Questionnaire data will include participant/respondent
contact information, demographics, access to preventive
health, falls screening questions, and health outcomes. All
data stored in TPFST will be maintained by the contractor,
NORC, on behalf of CDC.

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

As part of the data collection process, respondents will be
contacted via mail or telephone. Mailed letters will contain the
web link for the online survey, the respondent’s unique PIN,
and instructions on how to access the survey. Also,
respondents will have the option of calling the study’s toll-free
line at any time to complete the survey via telephone with a
trained data collection specialist.
Response data from the questionnaires will be used for
analysis purposes and to prepare reports, reporting
information in the aggregate. De-identified data files will be
delivered to the CDC twice throughout the survey; once at the
midpoint and at the end. A final, cleaned dataset will be
delivered at the end of the project.

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

Employees
Public Citizens
16

Business Partners/Contacts (Federal, state, local agencies)

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

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 will be used to contact participants, both initially and for
follow-up.
N/A

20 Describe the function of the SSN.

N/A

20a Cite the legal authority to use the SSN.

N/A

21

Identify legal authorities governing information use Public Health Service Act, Section 301, "Research and
and disclosure specific to the system and program.
Investigation" (42 U.S.C. 241).

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
Surveillance of Disease Problems"

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.

TBD
Yes
No
The contractor, NORC, uses a probability based panel designed
to be representative of the US population to produce a
nationally representative sample. Participant panels are
recruited from this sample. During this recruitment process,
potential participants are contacted, notified what is being
collected and given the opportunity to self-select the surveys
of interest to them.
They are later contacted for the actual survey, and during the
scripted introduction and screening, they are again given
notice and can consent or object to actual participation in the
survey.
Names and addresses are not delivered to CDC.

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26

Voluntary

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.

Mandatory
Individuals can opt-out of the study. During the introductory
script individuals will be advised that they can at any time optout of the study or refuse to answer any questions they do not
wish to answer.

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
Electronic or regular mail is sent when there are any major
28 and/or data uses have changed since the notice at
the time of original collection). Alternatively, describe changes to the system.
why they cannot be notified or have their consent
obtained.
Individuals with concerns about inappropriate attainment, use,
or disclosure as well as inaccuracy of their PII may report their
Describe the process in place to resolve an
individual's concerns when they believe their PII has concerns to the TPFST Information Systems Security Officer
29 been inappropriately obtained, used, or disclosed, or (ISSO) or the Contracting Officer's Representative (COR) for the
that the PII is inaccurate. If no process exists, explain contract that supports TPFST. They may also report the
incident to the Project Director for the contract that supports
why not.
TPFST and/or the TPFST Helpdesk where their concern must be
logged and submitted to CDC.

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.

31

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

Data collection will occur monthly over one year. Respondents
will be asked to confirm/update their contact information for
recontact in the future. Respondents can also contact the
project via a toll-free telephone number or project e-mail
address to alert the project staff to any changes in contact
information (name, address, phone). These methods will serve
as the primary manner in which the data is reviewed for
integrity, availability, accuracy, and relevancy.
Users

To conduct interviews or manage the
data collection process.

Administrators

Administrators have full rights to
maintain and and support the overall
system.

Developers
Contractors
Others

Describe the procedures in place to determine which
Role Based Access Control (RBAC) will be used to determine
32 system users (administrators, developers,
who has access to PII.
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 model will be used to allow those with
access to PII to be able to access the minimum amount of PII
needed to perform their job.

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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.

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

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

All NORC (contractor) employees are required to take Privacy
and IT Security Awareness training annually. This training has
been reviewed and is compatible with CDC requirements.
All NORC (contractor) staff are required to undergo annual
Ethics and Compliance training which has been reviewed and
is compatible with CDC requirements.
The project staff will receive system specific training prior to
system use. All project staff will be required to sign the
information system Rules of Behavior document and a nondisclosure agreement.
Yes
No
Records are retained and disposed of in accordance with the
CDC Records Control Schedule (N1-442-09-1) and in
accordance with contractual agreement. Record copy of study
reports are maintained in agency 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
tapes, burning or shredding paper materials or transferring
records to the Federal Records Center when no longer needed
for evaluation and analysis. Records are retained for 20 years;
for longer periods if further study is needed.
Administrative controls include a system security plan,
contingency plan, regular back up of files and storage of
backups off site, role-based security awareness training, least
privilege access enforced through Active Directory groups,
separate user and privileged accounts for administrators,
policies and procedures in place for retention and destruction
of PII, and a corporate incident response team and incident
response plans.
Technical controls include identification and authentication
using unique user IDs, passwords, and smart cards, use of
firewalls and intrusion detection/prevention systems, virus
scanning software on all computers, and a security information
and event management (SIEM) solution.
Physical controls include guards, identification badges, key
cards, and closed circuit TV.

General Comments

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OPDIV Senior Official
for Privacy Signature

Beverly E.
Walker -S

Digitally signed by
Beverly E. Walker -S
Date: 2017.09.15 18:21:53
-04'00'

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