A Privacy Act Notification Statement (NS) must be posted on all
websites, paper and electronic forms which collect information in
identifiable form (IIF), that is, information that is personal in nature
and which may be used to identify an individual.

[Examples of IIF]{.underline}: Name, date of birth, age, sex, gender,
racial ethnicity, SSN, patient/physician ID, protocol number, clinical
investigator number, grant application number, photo, voiceprint,
fingerprint, home address/phone/email, military rank, medical
credentials/specialty, Curriculum Vitae, license, educational
background, financial transactions, medical history, criminal or
employment history, or any other identifying number, symbol, or other
identifying particular assigned to the individual.

The NS must be inserted at the point at which an individual is asked to
provide the information. The NS must address the following 5 criteria:

[Privacy Act Notification Statement]{.underline}

1.  What is the Government Authorization (Statute or Exec Order)
    authorizing the information collection?

2.  What is the purpose of the information collection?

3.  What are the routine uses for information disclosure (who might you
    contact)?

4.  Is the request voluntary or mandatory?

5.  What effect, if any, will there be for not providing the
    information?

**[The following is a DRAFT sample notification statement that may
appear on a medical form given to patients seeking medical attention at
the Clinical Center]{.underline}**:

Collection of this information is authorized under 5 U.S.C. 7901. The
primary use of this information is to provide medical treatment at the
National Institutes of Health. This information may be disclosed to
researchers for research purposes, to HHS personnel offices for
determination of fitness for duty, and for disability retirement and
other separation actions, and to monitor personnel to assure that safety
standards are maintained. Submission of this information is voluntary,
however, in order for us to provide medical treatment, you should
complete all fields.

**[The following is the ACTUAL notification statement posted on the ITAS
system where NIH employees are asked to provide personal information
related to their request for pay and leave]{.underline}:**

**Privacy Act Notice**

**General** - This notice is provided pursuant to Public/ Law 93-579,
Privacy Act of 1974, 5, U.S.C. Section 552a, for individuals supplying
information as data input to NIH\'s Integrated Time and Attendance
System.

**Authority** - Section 5301 of Title 5 of the U.S. Code authorizes
collection of this information.

**Purposes and Uses** - The information entered into this data system
becomes a part of the NIH Payroll System and documents daily time and
attendance for employees. The primary use of the information is to
prepare the NIH payroll and compute leave balances. The information may
be used in and disclosure may be made to (1) W-2 forms for transmittal
to IRS and State and select local Governments; (2) Various listings,
tapes and schedules for transfer to the Department of Treasury for
issuance of salary payments; (3) Listings of moneys sent to financial
organizations biweekly for direct deposits; (4) Quarterly reports to
IRS; (5) Law enforcement; and (6) Reports to OPM for retirement
calculations. Data is aggregated to prepare various reports to OPM, the
Treasury, and other agencies, but such reports do not include
information by name or other identifying number of characteristics. (See
NIH-22, \"NIH Payroll System\").

**Effects of Nondisclosure** - Failure to supply the information could
prevent NIH from compensating said employee.

For assistance in drafting a Privacy Act Notification Statement, or
locating the PHS Act or Public Law that authorizes the IC or OD office
to operate, please contact the respective IC Privacy Coordinator at the
link below:

<http://oma.od.nih.gov/about/contact/browse.asp?fa_id=3>

[NOTE]{.underline}: The Office of General Counsel has experience in
reviewing and clearing privacy statements at the NIH level, and should
be considered an available resource. ICs can contact the NIH Legal
Advisor at (301) 496-6043, for any necessary assistance.

To inquire about establishing new NIH forms or to revise existing NIH
forms to include a Privacy Act Notification Statement, call the NIH
Forms Officer for information on (301) 496-8155 or email [Joanne
Eater](mailto:eaterj@od.nih.gov).