21 CRR-NY 1402.5NY-CRR
21 CRR-NY 1402.5
21 CRR-NY 1402.5
1402.5 Form of privacy impact statement.
The form of the privacy impact statement shall consist of the following:
PRIVACY IMPACT STATEMENT
Prepared pursuant to Public Officers Law, § 93
Personal Privacy Protection Law
__________________
Name of System of Records
1. Name of Agency Subdivision of agency maintaining
system of records
Title and business address of agency official responsible for system of records.
2.
Indicate procedures by which a data subject may gain access to personal information pertaining to such data subject in the system of records and the procedures by which a data subject may seek to amend or correct its contents (where appropriate, include legal reference to procedures and attached procedures as appendix).
3.
Identify categories of persons on whom records will be maintained in the system of records.
4.
Provide approximate number of persons about whom records will be maintained in the system of records.
5.
Describe or provide legal reference to policies governing retention and timely disposal of information within the system of records in accordance with law:
6. The system of records will be maintained (mark with “X”):
____ manually, ____by automated data system, ____ both
7. List below as indicated (include appendix if necessary):
in column (a), the categories of information which will be collected and maintained in the system of records;
in column (b), the purposes for which each category of information within the system of records will be collected and maintained;
in column (c), the general or specific statutory authority for the collection, maintenance and disclosure of each category of information within the system of records;
in column (d), each and every source for each category of information within the system;
in column (e), the disclosures of personal information within the system of records that the agency will regularly make for each category of information;
in column (f), the authority for regular disclosures identified in column (e).
(a) categories of information
(b) purposes
_____________
_____________
_____________
_____________
_____________
_____________
_____________
_____________
_____________
_____________
(c) statutory authority
(d) sources
_____________
_____________
_____________
_____________
_____________
_____________
_____________
_____________
_____________
_____________
(e) regular disclosures
(f) authority for each disclosure listed in column (e)
_____________
_____________
_____________
_____________
_____________
_____________
_____________
_____________
_____________
_____________
21 CRR-NY 1402.5
Current through May 31, 2021
| End of Document |