DDFORM 2930NOV 2008 Page1 of 15

PRIVACY IMPACT ASSESSMENT (PIA)

For the

SECTION 1: IS A PIA REQUIRED?

a. Will this Department of Defense (DoD) information system or electronic collection of 

information (referred to as an "electronic collection" for the purpose of this form) collect, 

maintain, use, and/or disseminate PII about members of the public, Federal personnel, 

contractors or foreign nationals employed at U.S. military facilities internationally? Choose 

one option from the choices below. (Choose (3) for foreign nationals).

 (1) Yes, from members of the general public.

(2) Yes, from Federal personnel* and/or Federal contractors.

 (3) Yes, from both members of the general public and Federal personnel and/or Federal contractors.

 (4) No

* "Federal personnel" are referred to in the DoD IT Portfolio Repository (DITPR) as "Federal employees."

b. If "No," ensure that DITPR or the authoritative database that updates DITPR is annotated 

for the reason(s) why a PIA is not required. If the DoD information system or electronic 

collection is not in DITPR, ensure that the reason(s) are recorded in appropriate 

documentation.

c. If "Yes," then a PIA is required. Proceed to Section 2.

SYSTOC

DLA Installation Support
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SECTION 2: PIA SUMMARY INFORMATION

a. Why is this PIA being created or updated? Choose one:

 New DoD Information System New Electronic Collection

 Existing DoD Information System Existing Electronic Collection

Significantly Modified DoD Information 

System

b. Is this DoD information system registered in the DITPR or the DoD Secret Internet Protocol 

Router Network (SIPRNET) IT Registry?

 Yes, DITPR Enter DITPR System Identification Number

 Yes, SIPRNET Enter SIPRNET Identification Number

No

c. Does this DoD information system have an IT investment Unique Project Identifier (UPI), required 

by section 53 of Office of Management and Budget (OMB) Circular A-11?

 Yes No

If "Yes," enter UPI

If unsure, consult the Component IT Budget Point of Contact to obtain the UPI.

d. Does this DoD information system or electronic collection require a Privacy Act System of 

Records Notice (SORN)?

A Privacy Act SORN is required if the information system or electronic collection contains information about U.S. citizens 

or lawful permanent U.S. residents that is retrieved by name or other unique identifier. PIA and Privacy Act SORN 

information should be consistent.

Yes No

If "Yes," enter Privacy Act SORN Identifier

DoD Component-assigned designator, not the Federal Register number.

Consult the Component Privacy Office for additional information or

access DoD Privacy Act SORNs at: http://www.defenselink.mil/privacy/notices/

or

Date of submission for approval to Defense Privacy Office

Consult the Component Privacy Office for this date.

OPM/GOVT–10
DDFORM 2930NOV 2008 Page3 of 15

e. Does this DoD information system or electronic collection have an OMB Control Number?

Contact the Component Information Management Control Officer or DoD Clearance Officer for this information.

This number indicates OMB approval to collect data from 10 or more members of the public in a 12-month period 

regardless of form or format.

 Yes

Enter OMB Control Number

Enter Expiration Date

No

f. Authority to collect information. A Federal law, Executive Order of the President (EO), or DoD 

requirement must authorize the collection and maintenance of a system of records.

(1) If this system has a Privacy Act SORN, the authorities in this PIA and the existing Privacy Act 

SORN should be the same.

(2) Cite the authority for this DoD information system or electronic collection to collect, use, maintain 

and/or disseminate PII. (If multiple authorities are cited, provide all that apply.)

(a) Whenever possible, cite the specific provisions of the statute and/or EO that authorizes 

the operation of the system and the collection of PII.

(b) If a specific statute or EO does not exist, determine if an indirect statutory authority can 

be cited. An indirect authority may be cited if the authority requires the operation or administration of 

a program, the execution of which will require the collection and maintenance of a system of records.

(c) DoD Components can use their general statutory grants of authority (“internal 

housekeeping”) as the primary authority. The requirement, directive, or instruction implementing the 

statute within the DoD Component should be identified.

Executive Orders 12107, 12196, and 12564 and 5 U.S.C. chapters 11, 33, and 63.
DDFORM 2930NOV 2008 Page4 of 15

g. Summary of DoD information system or electronic collection. Answers to these questions 

should be consistent with security guidelines for release of information to the public.

(1) Describe the purpose of this DoD information system or electronic collection and briefly 

describe the types of personal information about individuals collected in the system.

(2) Briefly describe the privacy risks associated with the PII collected and how these risks are 

addressed to safeguard privacy.

h. With whom will the PII be shared through data exchange, both within your DoD Component and 

outside your Component (e.g., other DoD Components, Federal Agencies)? Indicate all that apply.

Within the DoD Component.

Specify.

 Other DoD Components.

Specify.

 Other Federal Agencies.

Specify.

 State and Local Agencies.

Specify.

Contractor (Enter name and describe the language in the contract that safeguards PII.)

Specify.

SYSTOC is an electronic medical records system for use by the DLA Installation Support at Richmond 

Occupational Health Clinic. It is primarily used as for development and storage of electronic medical 

records, medical history and tracking to ensure compliance with annual medical surveillance requirements. 

Typical information contained in this system includes employee medical information related to occupational 

exposures and required occupational testing. The system will also store civilian information related to fitness 

for duty, workers' compensation examinations and treatment and physical exam findings related to the 

American's with Disabilities Act. On rare occasions, military service members may visit this clinic, and are 

referred to their appropriate treatment facility.

Personal Information collected include: Name, truncated social security number, date of birth, gender, 

military record information (if applicable).

Some privacy risks associated with PII collection were identified for SYSTOC: (1) unauthorized access 

(compromise of data resulting in identity theft would be critical as it would be a release of personal medical 

information, (2) unauthorized disclosure can result in identity theft or embarrassment.

Risk exposure of individual's private and personal information. The risks are minimized by physical, 

technical, and administrative controls. Data is available to only those whose job performances require 

access and is trained in privacy protection. System access is physically located in locked offices, controlled 

by use of smart cards, passwords, timed computer screen locks and role-based security which ensures 

access to the information in the system is limited by job requirement and authorization to view the data.

Physical access to the system is restricted by the use of security guards and door locks and laptop locks.

DLA Installation Support Occupational Health Physician, Nurse and Medical 

Assistant.

Federal Staffing Resources contract (SP4703-08-C-0010) Section 7.1 Maintenance of
 Other (e.g., commercial providers, colleges).

Specify.

i. Do individuals have the opportunity to object to the collection of their PII?

Yes No

(1) If "Yes," describe method by which individuals can object to the collection of PII.

(2) If "No," state the reason why individuals cannot object.

j. Do individuals have the opportunity to consent to the specific uses of their PII?

Yes No

(1) If "Yes," describe the method by which individuals can give or withhold their consent.

(2) If "No," state the reason why individuals cannot give or withhold their consent.

DDFORM 2930NOV 2008 Page5 of 15

Medical Records: The contractor shall maintain all records under this contract in 

accordance with the Privacy act of 1974 and DLAR 5400.21. All records produced 

under this contract will remain the property of the Government.

Individuals may object to the collection of their PII, however their objection would lead to the inability to 

perform the required work-related medical examinations. Typical medical examination required by law 

include the following: annual audiogram testing under 29 CFR 1910.95, Asbestos medical Surveillance 

under 29 CFR 1910.1101 and medical evaluation for respirator use under 29 CFR 1910.134.

Individuals may object to the collection of their PII, however their objection would lead to the inability to 

perform the required work-related medical examinations. Typical medical examination required by law 

include the following: annual audiogram testing under 29 CFR 1910.95, Asbestos medical Surveillance 

under 29 CFR 1910.1101 and medical evaluation for respirator use under 29 CFR 1910.134.
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k. What information is provided to an individual when asked to provide PII data? Indicate all that 

apply.

Privacy Act Statement Privacy Advisory

 Other None

Describe 

each 

applicable 

format.

NOTE:

Sections 1 and 2 above are to be posted to the Component's Web site. Posting of these 

Sections indicates that the PIA has been reviewed to ensure that appropriate safeguards are in 

place to protect privacy.

A Component may restrict the publication of Sections 1 and/or 2 if they contain information that 

would reveal sensitive information or raise security concerns.

The individuals are provided a DD Form 2005 (Health Care Records), which contains a privacy act 

statement which states that the information collection is voluntary and the consequences of choosing 

not to participate in the information collection. The form is publicly posted at the DLA Installation 

Support Richmond Occupational Health Clinic and a signed form is kept with each individual's 

permanent medical file.
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