ML24138A059
| ML24138A059 | |
| Person / Time | |
|---|---|
| Issue date: | 04/01/2024 |
| From: | Bowman K NRC/OCIO/CISD |
| To: | |
| Bowman K | |
| References | |
| Download: ML24138A059 (1) | |
Text
U.S. Nuclear Regulatory Commission Privacy Impact Assessment Employee Medical File (EMF)
Health Emergency Records - NRC SORN 46 Office of the Chief Human Capital Officer (OCHCO)
Version 1.0 04/01/2024 Template Version 2.0 (08/2023)
Employee Medical File (EMF)
Version 1.0 Privacy Impact Assessment 04/01/2024 Document Revision History Date Version PIA Name/Description Author 04/01/2024 1.0 Employee Medical File (EMF)
Emergency Health Records - NRC SORN 46 Initial Release Kathrine Bowman
Employee Medical File (EMF)
Version 1.0 Privacy Impact Assessment 04/01/2024 Table of Contents 1
Description 1
2 Authorities and Other Requirements 2
3 Characterization of the Information 4
4 Data Security 5
5 Privacy Act Determination 7
6 Records and Information Management-Retention and Disposal 9
7 Paperwork Reduction Act 13 8
Privacy Act Determination 14 9
OMB Clearance Determination 15 10 Records Retention and Disposal Schedule Determination 16 11 Branch Chief Review and Concurrence 17
Employee Medical File (EMF)
Version 1.0 Privacy Impact Assessment 04/01/2024 PIA Template (08-2023) 1 The agency is subject to the requirements of the E-Government Act and is committed to identifying and addressing privacy risks whenever it develops or makes changes to its information systems. The questions below help determine any privacy risks related to the E-Government Act or later guidance by the Office of Management and Budget (OMB) and the National Institute of Standards and Technology (NIST).
Name/System/Subsystem/Service Name:
Employee Medical File (EMF)
Health Emergency Records - NRC SORN 46 Data Storage Location (i.e., Database Server, SharePoint, Cloud, Other Government Agency, Power Platform)
SharePoint database Date Submitted for review/approval: April 16, 2024 Note: When completing this PIA do not include any information that would raise security concerns or prevent this document from being made publicly available.
1 Description 1.1 Provide the description of the system/subsystem, technology (i.e., Microsoft Products), program, or other data collections (hereinafter referred to as project).
Explain the reason the project is being created.
This system is to maintain records necessary and relevant to NRC activities responding to and mitigating high-consequence public health threats, including, but not limited to: COVID-19 or diseases and illnesses relating to a public health emergency, pandemic, or other high-consequence public health threat. Records may include, but are not limited to, those applicable health related records needed to understand the impact of an illness or disease on the NRC workforce, to assist the NRC in protecting its workforce from a declared public health emergency, pandemic, or other high-consequence public health threat, as well as those records submitted by NRC personnel, or their lawful representative of such personnel. Information collected may also satisfy requirements resulting from an Executive Order of other Federal law.
Please mark appropriate response below if your project/system will involve the following:
PowerApps Public Website Dashboard Internal Website SharePoint None Other Email
Employee Medical File (EMF)
Version 1.0 Privacy Impact Assessment 04/01/2024 PIA Template (08-2023) 2 1.2 Does this privacy impact assessment (PIA) support a proposed new project, proposed modification to an existing project, or other situation? Select options that best apply in table below.
Mark appropriate response.
Status Options
New system/project
Modification to an existing system/project.
If modifying or making other updates to an existing system/project, provide the ADAMS ML of the existing PIA and describe the modification.
Data contents has been modified. COVID-19 data is no longer being tracked as a result of recent revocation of EO 14043, Requiring Coronavirus Disease 2019 Vaccination for Federal Employees. File will be maintained for episodic or event-driven requirements and will contain health-related information as required by law imposing compliance.
Annual Review If making minor edits to an existing system/project, briefly describe the changes below.
<Insert response here >
Other (explain) 1.3 Points of
Contact:
(Do not adjust or change table fields. Annotate N/A if unknown. If multiple individuals need to be added in a certain field, please add lines where necessary.)
Project Manager System Owner/Data Owner/Steward ISSO Business Project Manager Technical Project Manager Executive Sponsor Name Kathrine Bowman Kathrine Bowman N/A N/A Basia Sall Eric Dilworth Office/Division
/Branch OCHCO OCHCO OCIO N/A OCICO/SDOD OCHCO Telephone 301-752-0191 301-752-0191 N/A N/A N/A N/A 2 Authorities and Other Requirements 2.1 What specific legal authorities and/or agreements permit the collection of information for the project?
Provide all statutory and regulatory authorities for operating the project, including the authority to collect the information; NRC internal policy is not a legal authority. Please mark appropriate response in table below.
Employee Medical File (EMF)
Version 1.0 Privacy Impact Assessment 04/01/2024 PIA Template (08-2023) 3 Mark with an X on all that apply.
Authority Citation/Reference
Statute 75 Fed. Reg. 35099 (June 21, 2010),
amended 80 Fed.
Reg. 74815 (Nov. 30, 2015), also includes 5 U.S.C. chapters 33 and 63 5 U.S.C. 7902, Safety Programs 44 U.S.C. 3101; the Religious Freedom Restoration Act of 1933 42 U.S.C. Chapter 21B; Title VII of the Civil Rights Act of 1964, as amended 42 U.S.C. 2000e The Rehabilitation Act of 1973, as amended, 29 U.S.C. 701 et seq.
PREVENT Pandemics Act, 42 U.S.C. § 300hh-3, December 29, 2022
Executive Order EO 12196, Occupational Safety and Health Programs for Federal Employees EO 13996, Establishing the COVID-19 Pandemic Testing Board and Ensuring a Sustainable Public Health Workforce for COVID-19 and Other Biological Threats
Federal Regulation
Memorandum of Understanding/Agreement
Other (summarize and provide a copy of relevant portion) 2.2 Explain how the information will be used under the authority listed above (i.e., enroll employees in a subsidies program to provide subsidy payment).
This information is being collected and maintained to promote the safety of Federal workplaces and the Federal workforce consistent with the above-referenced authorities, the
Employee Medical File (EMF)
Version 1.0 Privacy Impact Assessment 04/01/2024 PIA Template (08-2023) 4 NRC Workplace Safety Plan in conjunction with guidance from Centers for Disease Control and Prevention and the Occupational Safety and Health Administration.
If the project collects Social Security numbers, state why this is necessary and how it will be used.
N/A 3 Characterization of the Information In the table below, mark the categories of individuals for whom information is collected.
Category of individual
Federal employees
Contractors
Members of the Public (any individual other than a federal employee, consultant, or contractor)
Licensees
Other <Insert response here>
In the table below, is a list of the most common types of PII collected. Mark all PII that is collected and stored by the project/system. If there is additional PII not defined in the table below, a comprehensive listing of PII is provided for further reference in ADAMS at the following link: PII Reference Table 2023.
Categories of Information
Name
Resume or curriculum vitae
Date of Birth
Driver's License Number
Country of Birth
License Plate Number
Citizenship
Passport number
Nationality
Relatives Information
Race
Taxpayer Identification Number
Home Address
Credit/Debit Card Number
Social Security number (Truncated or Partial)
Medical/health information
Gender
Alien Registration Number
Ethnicity
Professional/personal references
Spouse Information
Criminal History
Personal e-mail address
Biometric identifiers (facial images, fingerprints, iris scans)
Personal Bank Account Number
Emergency contact e.g., a third party to contact in case of an emergency
Employee Medical File (EMF)
Version 1.0 Privacy Impact Assessment 04/01/2024 PIA Template (08-2023) 5 Categories of Information
Personal Mobile Number
Accommodation/disabilities information
Marital Status
Children Information
Mother's Maiden Name
Other: EmplD Religious Affiliation 3.1 Describe how the data is collected for the project. (i.e., NRC Form, survey, questionnaire, existing NRC files/ databases, response to a background check).
Data will be collected in NRC system on NRC digital platforms.
3.2 If using a form to collect the information, provide the form number, title and/or a link.
N/A 3.3 Who provides the information? Is it provided directly from the individual or a third party.
To be provided by employees or their designated representative.
3.4 Explain how the accuracy of the data collection is validated. If the project does not check for accuracy, please explain why.
To be provided by employees or their designated representative.
3.5 Will PII data be used in a test environment? If so, explain the rationale.
N/A 3.6 What procedures are in place to allow the subject individual to correct inaccurate or erroneous information?
Self-validation or validation completed by designated representative.
4 Data Security 4.1 Describe who has access to the data in the project (i.e., internal NRC, system administrators, external agencies, contractors, public).
Program Manager, Chief Human Capital Officer, System Owner/Data Owner/Steward, ISSO, Technical Project Manager
Employee Medical File (EMF)
Version 1.0 Privacy Impact Assessment 04/01/2024 PIA Template (08-2023) 6 4.2 If the project/system shares information with any other NRC systems, identify the system, what information is being shared and the method of sharing.
N/A 4.3 If the project/system connects, receives, or shares information with any external non-NRC partners or systems, identify what is being shared.
N/A Identify what agreements are in place with the external non-NRC partner or system in the table below.
Agreement Type
Contract Provide Contract Number:
License Provide License Information:
Memorandum of Understanding Provide ADAMS ML number for MOU:
Other
None 4.4 Describe how the data is accessed and describe the access control mechanisms that prevent misuse.
Access is restricted to only those who have a need to know.
4.5 Explain how the data is transmitted and how confidentiality is protected (i.e.,
encrypting the communication or by encrypting the information before it is transmitted).
When data is required to be transmitted for reporting purposes, data will be encrypted in accordance with privacy act requirements.
4.6 Describe where the data is being stored (i.e., NRC, Cloud, Contractor Site).
Data will be stored in NRC developed system on NRC digital platform.
4.7 Explain if the project can be accessed or operated at more than one location.
No.
4.8 Can the project be accessed by a contractor? If so, do they possess an NRC badge?
N/A
Employee Medical File (EMF)
Version 1.0 Privacy Impact Assessment 04/01/2024 PIA Template (08-2023) 7 4.9 Explain the auditing measures and technical safeguards in place to prevent misuse of data.
The NRC safeguards records in this system according to applicable rules and polices, including all applicable NRC automated systems security and access policies. The NRC has imposed controls to minimize the risk of compromising the information that is being stored. Users of individual computers can only gain access to the data by valid user identification and password.
Paper records, if maintained, are in a secure, access-controlled room, with access limited to authorized personnel.
4.10 Describe if the project has the capability to identify, locate, and monitor (i.e.,
trace/track/observe) individuals.
N/A 4.11 Define which FISMA boundary this project is part of.
ITI 4.12 Is there an Authority to Operate (ATO) associated with this project/system?
Authorization Status
Unknown
No If no, please note that the authorization status must be reported to the Chief Information Security Officer (CISO) and Computer Security Organization (CSOs)
Point of Contact (POC) via e-mail quarterly to ensure the authorization remains on track.
In Progress provide the estimated date to receive an ATO.
Estimated date: <insert appropriate response>
Yes Indicate the data impact levels (Low, Moderate, High, Undefined) approved by the Chief Information Security Officer (CISO)
Confidentiality - Moderate Integrity - Moderate Availability - Moderate 4.13 Provide the NRC system Enterprise Architecture (EA)/Inventory number. If unknown, contact EA Service Desk to get the EA/Inventory number.
EA# 20090005
Employee Medical File (EMF)
Version 1.0 Privacy Impact Assessment 04/01/2024 PIA Template (08-2023) 8 5 Privacy Act Determination 5.1 Is the data collected retrieved by a personal identifier?
Mark the appropriate response.
Response
Yes, the PII is retrieved by a personal identifier (i.e., individuals name, address, SSN, etc.)
List the identifiers that will be used to retrieve the information on the individual.
Employee name, Emplid
No, the PII is not retrieved by a personal identifier.
If no, explain how the data is retrieved from the project.
<Insert response here>
5.2 For all collections where the information is retrieved by a personal identifier, the Privacy Act requires that the agency publish a System of Record Notice (SORN) in the Federal Register. As per the Privacy Act of 1974, "the term 'system of records' means a group of any records under the control of any agency from which information is retrieved by the name of the individual or by some other personal identifier assigned to the individual.
Mark the appropriate response in the table below.
Response
Yes, this system is covered by an existing SORN. (See existing SORNs:
https://www.nrc.gov/reading-rm/foia/privacy-systems.html )
Provide the SORN name, number, (List all SORNs that apply):
Health Emergency Records - NRC 46 SORN is being modified
SORN is in progress
SORN needs to be created
Unaware of an existing SORN
No, this system is not a system of records and a SORN is not applicable.
Employee Medical File (EMF)
Version 1.0 Privacy Impact Assessment 04/01/2024 PIA Template (08-2023) 9 5.3 When an individual is asked to provide personal data (i.e., form, webpage, survey), is a Privacy Act Statement (PAS) provided?
A Privacy Act Statement is a disclosure statement required to appear on documents used by agencies when an individual is asked to provide personal data. It is required for any forms, surveys, or other documents, including electronic forms, used to solicit personal information from individuals that will be maintained in a system of records.
Mark the appropriate response.
Options
Privacy Act Statement (Insert link to Privacy Act Statement (PAS) for each form, webpage or survey etc.)
Not Applicable - but will provide when needed
Unknown 5.4 Is providing the PII mandatory or voluntary? What is the effect on the individual by not providing the information?
PII is mandatory to track employee compliance with Federal mandate to provide applicable health related medical information. Not providing PII (employee name) would hinder NRC from monitoring employee compliance with law.
6 Records and Information Management-Retention and Disposal The National Archives and Records Administration (NARA), in collaboration with federal agencies, approves whether records are Temporary (eligible at some point for destruction/deletion because they no longer have business value) or Permanent (eligible at some point to be transferred to the National Archives because of historical or evidential significance). Records/data and information with historical value, identified as having a permanent disposition, are transferred to the National Archives of the United States at the end of their retention period. All other records identified as having a temporary disposition are destroyed at the end of their retention period in accordance with the NARA Records Schedule or the General Records Schedule.
These determinations are made through records retention schedules and NARA statutes (44 United States Code (U.S.C.), 36 Code of Federation Regulations (CFR)). Under 36 CFR, agencies are required to establish procedures for addressing Records and Information Management (RIM) requirements. This includes strategies for establishing and managing recordkeeping requirements and disposition instructions before approving new electronic information systems or enhancements to existing systems.
The following questions are intended to determine whether the records/data and information in the system have approved records retention schedules and disposition instructions, whether the
Employee Medical File (EMF)
Version 1.0 Privacy Impact Assessment 04/01/2024 PIA Template (08-2023) 10 system incorporates RIM strategies including support for NARAs Universal Electronic Records Management (ERM) requirements, and if a mitigation strategy is needed to ensure compliance.
If the project/system:
Does not have an approved records retention schedule and/or Does not have an automated RIM functionality, Involves a cloud solution, And/or if there are additional questions regarding Records and Information Management
- Retention and Disposal, please contact the NRC Records staff at ITIMPolicy.Resource@nrc.gov for further guidance.
If the project/system has a record retention schedule or an automated RIM functionality, please complete the questions below.
6.1 Does this project map to an applicable retention schedule in NRCs Comprehensive Records Disposition Schedule (NUREG-0910), or NARAs General Records Schedules?
NUREG-0910, NRC Comprehensive Records Disposition Schedule
NARAs General Records Schedules
Unscheduled 6.2 If so, cite the schedule number, approved disposition, and describe how this is accomplished.
System Name (include sub-systems, platforms, or other locations where the same data resides)
Employee Medial File (EMF)
Emergency Health Records -
NRC SORN 46 Records Retention Schedule Number(s)
GRS 2.7 item 010 - Clinic scheduling records GRS 2.7 item 070 - Non-occupational individual medical case files GRS 2.7 item 080 - Non-occupational health and wellness program records GRS 2.7 - item 063 -
Vaccination attestations and proof of vaccinations records.
Federal employees and contractors.
Employee Medical File (EMF)
Version 1.0 Privacy Impact Assessment 04/01/2024 PIA Template (08-2023) 11 Approved Disposition Instructions GRS 2.7 item 010 (DAA-GRS-2017-0010-0001)
Clinic scheduling records.
Temporary. Destroy when 3 years old, but longer retention is authorized if needed for business us GRS 2.7 - item 063 (DAA-GRS-2021-0003-0001)
Temporary. Destroy when 3 years old.
GRS 2.7 item 070 (DAA-GRS-2017-0010-0012)
Non-occupational individual case files.
Temporary. Destroy 10 years after the most recent encounter, but longer retention is authorized if needed for business use GRS 2.7 item 080 (DAA-GRS-2017-0010-0013)
Non-occupational health and wellness program records.
Temporary. Destroy 3 years after the project/activity/or transaction is completed or superseded, but longer retention is authorized if needed for business use.
Employee Medical File (EMF)
Version 1.0 Privacy Impact Assessment 04/01/2024 PIA Template (08-2023) 12 Is there a current automated functionality or a manual process to support RIM requirements? This includes the ability to apply records retention and disposition policies in the system(s) to support records accessibility, reliability, integrity, and disposition.
To the extent applicable, to ensure compliance with Americans with Disabilities Act, the Rehabilitation Act, and the Genetic Information Nondiscrimination Act of 2008, medical information must be maintained on separate forms and in separate medical files and be treated as a confidential medical record. 42 U.S.C.
12112(d)(3)(B); 42 U.S.C. sec 2000ff-5(a); 29 CFR 1630.14(b)(1), (c)(1),(d)(4)(i);
and 29 CFR 1635.9(a). This means that medical information and documents must be stored separately from other personnel records. As such, the NRC must keep medical records for at least 1 year from creation date. 29 CFR 1602.14. Further, records compiled under this system of records notice will be maintained in accordance with the National Archives and Records Administration General Records Schedule (GRS) 2.7, Employee Health and Safety Records, Items 010, 070, or 080 to the extent applicable.
Disposition of Temporary Records Will the records/data or a composite be automatically or manually deleted once they reach their approved retention?
TBD Information will be managed in SharePoint or in MS Exchange (Emails)
Disposition of Permanent Records Will the records be exported to an approved format and transferred to the National Archives based on approved retention and disposition instructions?
If so, what formats will be used?
NRC Transfer Guidance (Information and Records Management Guideline -
IRMG)
Records will not be transferred to National Archives. Records will be maintained internally and purged when no longer needed or records destruction time frame is reached.
Employee Medical File (EMF)
Version 1.0 Privacy Impact Assessment 04/01/2024 PIA Template (08-2023) 13 Note: Information in Section 6, Records and Information Management-Retention and Disposal, does not need to be fully resolved for final approval of the privacy impact assessment.
7 Paperwork Reduction Act The Paperwork Reduction Act (PRA) of 1995 requires that agencies obtain an Office of Management and Budget (OMB) approval in the form of a "control number"before promulgating a paper form, website, surveys, questionnaires, or electronic submission from 10 or more members of the public. If the data collection is from federal employees regarding work-related duties, then a PRA clearance is not necessary.
7.1 Will the project be collecting any information from 10 or more persons who are not Federal employees?
N/A 7.2 Is there any collection of information addressed to all or a substantial majority of an industry (i.e., Fuel Fabrication Facilities or Fuel Cycle Facilities)?
For compliance with the Federal mandate, it is more likely than not that the impact would be to all Federal Employees but that would be determined by the Federal mandate (i.e. Executive Order (EO) from the President) 7.3 Is the collection of information required by a rule of general applicability?
No Note: For information collection (OMB clearances) questions: contact the NRCs Clearance Officer. Additional guidance can be found on the NRCs internal Information Collections Web page at: https://intranet.nrc.gov/ocio/33456.
Employee Medical File (EMF)
Version 1.0 Privacy Impact Assessment 04/01/2024 PIA Template (08-2023) 14 8 Privacy Act Determination Project/System Name: Employee Medical File (EMF)
Submitting Office: Office of the Chief Human Capital Officer (OCHCO)
Privacy Officer Review Review Results Action Items
This project/system does not contain PII.
No further action is necessary for Privacy.
This project/system does contain PII; the Privacy Act does NOT apply, since information is NOT retrieved by a personal identifier.
Must be protected with restricted access to those with a valid need-to-know.
This project/system does contain PII; the Privacy Act does apply.
SORN is required-Information is retrieved by a personal identifier.
Comments:
Covered by NRC 46 - Health Emergency Records Reviewers Name Title Privacy Officer Signed by Hardy, Sally on 05/31/24
Employee Medical File (EMF)
Version 1.0 Privacy Impact Assessment 04/01/2024 PIA Template (08-2023) 15 9 OMB Clearance Determination NRC Clearance Officer Review Review Results
No OMB clearance is needed.
OMB clearance is needed.
Currently has OMB Clearance. Clearance No.
Comments:
The system does not need a clearance as it is only repository of medical information and is not the instrument the agency uses to collect that information. If the agency collects information provided by a non-Federal medical provider, that information collection will need to be approved by OMB.
Reviewers Name Title Agency Clearance Officer Signed by Cullison, David on 05/31/24
Employee Medical File (EMF)
Version 1.0 Privacy Impact Assessment 04/01/2024 PIA Template (08-2023) 16 10 Records Retention and Disposal Schedule Determination Records Information Management Review Review Results
No record schedule required.
Additional information is needed to complete assessment.
Needs to be scheduled.
Existing records retention and disposition schedule covers the system - no modifications needed.
Comments:
Reviewers Name Title Sr. Program Analyst, Electronic Records Manager Signed by Dove, Marna on 05/31/24
Employee Medical File (EMF)
Version 1.0 Privacy Impact Assessment 04/01/2024 PIA Template (08-2023) 17 11 Branch Chief Review and Concurrence Review Results
This project/system does not collect, maintain, or disseminate information in identifiable form.
This project/system does collect, maintain, or disseminate information in identifiable form.
I concur with the Privacy Act, Information Collections, and Records Management reviews.
Director Chief Information Security Officer Chief Information Security Division Office of the Chief Information Officer Signed by Feibus, Jonathan on 06/03/24
Employee Medical File (EMF)
Version 1.0 Privacy Impact Assessment 04/01/2024 PIA Template (08-2023) 18 ADDITIONAL ACTION ITEMS/CONCERNS Name of Project/System:
Employee Medical File (EMF) - SORN 46 Date CISD received PIA for review:
April 16, 2024 Date CISD completed PIA review:
June 3, 2024 Action Items/Concerns:
Copies of this PIA will be provided to:
Gwen Hayden Acting Director IT Services Development and Operations Division Office of the Chief Information Officer Katie Harris Acting Deputy Chief Information Security Officer (CISO)
Office of the Chief Information Officer