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###### Department of Veterans Affairs

# AGENCY:

Department of Veterans Affairs (VA).

# ACTION:

Notice of Establishment of New System of Records.

# SUMMARY:

The Privacy Act of 1974 (5 U.S.C. 552(e) (4)) requires that all agencies publish in the Federal Register a notice of the existence and character of their systems of records. Notice is hereby given that the Department of Veterans Affairs (VA) is establishing a new system of records entitled “Suicide Prevention Database-VA” (158VA11).

# DATES:

Comments on this new system of records must be received no later than November 22, 2010. If no public comment is received, the new system will become effective November 22, 2010.

# ADDRESSES:

                        Written comments concerning the proposed amended system of records may be submitted by: mail or hand-delivery to Director, Regulations Management (02REG), Department of Veterans Affairs, 810 Vermont Avenue, NW., Room 1068, Washington, DC 20420; fax to (202) 273-9026; or e-mail to                         *http://www.Regulations.gov.*                         All comments received will be available for public inspection in the Office of Regulation Policy and Management, Room 1063B, between the hours of 8 a.m. and 4:30 p.m., Monday through Friday (except holidays). Please call (202) 461-4902 (this is not a toll-free number) for an appointment.                    

# FOR FURTHER INFORMATION CONTACT:

Janet Kemp RN, Ph.D., Department of Veterans Affairs, 400 Fort Hill Avenue, Canandaigua, NY 14424; telephone (585) 393-7939.

# SUPPLEMENTARY INFORMATION:

## I. Description of Proposed Systems of Records

The Suicide Prevention Database will serve two purposes. First, the database will store records associated with the National Suicide Hotline call logs via the National Suicide Hotline Web Application Program. The National Suicide Hotline Web Application Program is an electronic call log database that stores information from a Hotline call. In addition to the ability to retrieve and view information obtained from the calls the Web Interface program performs the following functions:

1. The system accepts Hotline calls and stores them according to the following:

a. Anonymous persons with incomplete identification information;

b. All Veterans, including Veterans who are not registered in the VA health care system (non-VA);

c. From family and friends of the affected Veteran:

○ In this case, the system shall indicate that the call was not made from the affected Veteran.

2. The system provides a mechanism for Hotline staff to identify the VA Medical Center closest to the caller's physical location;

3. The system provides a means for recording Hotline referrals in the Veteran's electronic medical record when the referral is made to a VA Medical Center for follow-up care;

4. The system provides a means for Suicide Prevention Coordinators to document their follow-up measures;

5. The system provides access to call log data for reporting purposes. The data will be used to provide information related to the number of calls, caller's demographic information, the types of calls, and follow-up care.

In addition to the National Suicide Hotline call logs via the National Suicide Hotline Web Application Program, the “Suicide Prevention Database-VA” will maintain Suicide Attempts and Completions information. This information is documented using the Statistical Package for the Social Sciences (SPSS). Information collected in SPSS includes attempt or completion, military conflict, VA enrolled, gender, age, mental health diagnosis, medical diagnosis, previous attempts, month of event, method used, outcome, intent, seen at a VA within 7 days of attempt, seen at VA within 30 days of attempt, where seen, had suicide been addressed, and last recorded pain score. The data will be used to generate national reports. In addition, the information obtained will be used to develop further VA educational programs and research opportunities surrounding suicide prevention.

## II. Proposed Routine Use Disclosures of Data in the System

We are proposing to establish the following Routine Use disclosures of information maintained in the system:

                    1. The record of an individual who is covered by a system of records may be                           ( print page 65061)                        disclosed to a Member of Congress, or a staff person acting for the Member, when the Member or staff person requests the record on behalf of and at the written request of the individual.                

2. Disclosure may be made to National Archives and Records Administration (NARA) and the General Services Administration (GSA) in records management inspections conducted under authority of Title 44, Chapter 29, of the United States Code (U.S.C). NARA and GSA are responsible for management of old records no longer actively used, but which may be appropriate for preservation, and for the physical maintenance of the Federal government's records. VA must be able to provide the records to NARA and GSA in order to determine the proper disposition of such records.

3. Disclosure may be made to other Government agencies in support of data exchanges of electronic medical record information approved by the individual.

4. VA may disclose on its own initiative any information in this system, except the names and home addresses of Veterans and their dependents, that is relevant to a suspected or reasonably imminent violation of law, whether civil, criminal or regulatory in nature and whether arising by general or program statute or by regulation, rule or order issued pursuant thereto, to a Federal, State, local, tribal, or foreign agency charged with the responsibility of investigating or prosecuting such violation, or charged with enforcing or implementing the statute, regulation, rule or order. VA may also disclose on its own initiative the names and addresses of veterans and their dependents to a Federal agency charged with the responsibility of investigating or prosecuting civil, criminal or regulatory violations of law, or charged with enforcing or implementing the statute, regulation, rule or order issued pursuant thereto.

5. VA may disclose information from this system of records to the Department of Justice (DoJ), either on VA's initiative or in response to DoJ's request for the information, after either VA or DoJ determines that such information is relevant to DoJ's representation of the United States or any of its components in legal proceedings before a court or adjudicative body, provided that, in each case, the agency also determines prior to disclosure that release of the records to the DoJ is a use of the information contained in the records that is compatible with the purpose for which VA collected the records. VA, on its own initiative, may disclose records in this system of records in legal proceedings before a court or administrative body after determining that the disclosure of the records to the court or administrative body is a use of the information contained in the records that is compatible with the purpose for which VA collected the records.

6. Disclosures of relevant information may be made to individuals, organizations, private or public agencies, or other entities with whom VA has a contract or agreement or where there is a subcontract to perform the services as VA may deem practicable for the purposes of laws administered by VA, in order for the contractor or subcontractor to perform the services of the contract or agreement. This routine use includes disclosures by the individual or entity performing the service for VA to any secondary entity or individual to perform an activity that is necessary for individuals, organizations, private or public agencies, or other entities or individuals with whom VA has a contract or agreement to provide the service to VA.

7. Disclosure to other Federal agencies may be made to assist such agencies in preventing and detecting possible fraud or abuse by individuals in their operations and programs.

8. VA may disclose information to the Equal Employment Opportunity Commission when requested in connection with investigations of alleged or possible discriminatory practices, examination of Federal affirmative employment programs, or for other functions of the Commission as authorized by law or regulation. VA must be able to provide information to the Commission to assist it in fulfilling its duties to protect employee's rights, as required by statute and regulation.

9. VA may disclose to the Fair Labor Relations Authority (FLRA) (including its General Counsel) information related to the establishment of jurisdiction, the investigation and resolution of allegations of unfair labor practices, or information in connection with the resolution of exceptions to arbitration awards when a question of material fact is raised; to disclose information in matters properly before the Federal Services Impasse Panel, and to investigate representation petitions and conduct or supervise representation elections. VA must be able to provide information to FLRA to comply with the statutory mandate under which it operates.

10. VA may disclose information to officials of the Merit Systems Protection Board (MSPB), or the Office of Special Counsel, when requested in connection with appeals, special studies of the civil service and other merit systems, review of rules and regulations, investigation of alleged or possible prohibited personnel practices, and such other functions, promulgated in 5 U.S.C. 1205 and 1206, or as authorized by law.

11. VA may, on its own initiative, disclose any information or records to appropriate agencies, entities, and persons when (1) VA suspects or has confirmed that the integrity or confidentiality of information in the system of records has been compromised; (2) the Department has determined that as a result of the suspected or confirmed compromise, there is a risk of embarrassment or harm to the reputations of the record subjects, harm to economic or property interests, identity theft or fraud, or harm to the security, confidentiality, or integrity of this system or other systems or programs (whether maintained by the Department or another agency or disclosure is to agencies, entities, or persons whom VA determines are reasonably necessary to assist or carry out the Department's efforts to respond to the suspected or confirmed compromise and prevent, minimize, or remedy such harm. This routine use permits disclosures by the Department to respond to a suspected or confirmed data breach, including the conduct of any risk analysis or provision of credit protection services as provided in 38 U.S.C. 5724, as the terms are defined in 38 U.S.C. 5727.

## III. Compatibility of the Proposed Routine Uses

The Privacy Act permits VA to disclose information about individuals without their consent for a routine use when the information will be used for a purpose that is compatible with the purpose for which we collected the information. In all of the routine use disclosures described above, the recipient of the information will use the information in connection with a matter relating to one of VA's programs, will use the information to provide a benefit to VA, or disclosure is required by law.

The notice of intent to publish and an advance copy of the system notice have been sent to the appropriate Congressional committees and to the Director of the Office of Management and Budget (OMB) as required by 5 U.S.C. 552a(r) (Privacy Act) and guidelines issued by OMB (65 FR 77677), December 12, 2000.

Approved: September 28, 2010.

John R. Gingrich,

Chief of Staff, Department of Veterans Affairs.

## 158VA11

### SYSTEM NAME:

                        “Suicide Prevention Database—VA”.                              ( print page 65062)    

### SYSTEM LOCATION:

The “Suicide Prevention Database—VA” will be maintained at Canandaigua VA Medical Center, 400 Fort Hill Avenue, Canandaigua, NY 14424. The back-up computer tape information is stored off-site at Albany VA Medical Center.

In addition, information from these records or copies of records may be maintained at the Department of Veterans Affairs, 810 Vermont Avenue, NW., Washington, DC.

### Categories of individuals covered by the system:

The records include information concerning Veterans and friends and family of Veterans who access the National Suicide Hotline. In addition, records include the name of the Hotline call responder and the name of the Suicide Prevention Coordinator.

### Categories of records in the system:

The records may include information related to:

1. The National Suicide Hotline call logs via the National Suicide Hotline Web Application Program includes the following information:

a. Identifies, by full name, the Hotline call responder;

b. Identifies, by full name, the Suicide Prevention Coordinator;

c. Records calls to the National Suicide Hotline which may be:

(1) Calls from an anonymous person with incomplete identification information;

(2) Calls from a Veteran, including Veterans who are not registered in VA health care system (non-VA);

(3) Calls from family and friends of the affected Veteran (In this case, the system shall indicate that the call was not made from the affected Veteran).

d. Identifies the VA Medical Center closest to the caller's physical location;

e. Records Hotline referrals in the Veteran's electronic medical record when the referral is made to a VA Medical Center for follow-up care;

f. Provides a means for Suicide Prevention Coordinators to document their follow-up measures;

g. Provides access to call log data for reporting purposes: Provides information related to the number of calls, callers demographic information, the types of calls, and follow-up care.

2. The Suicide Attempts and Completions data is collected in the SPSS statistical package. The information includes attempt or completion, military conflict, VA enrolled, gender, age, mental health diagnosis, medical diagnosis, previous attempts, month of event, method used, outcome, intent, seen at a VA within 7 days of attempt, seen at VA within 30 days of attempt, where seen, had suicide been addressed, and last recorded pain score.

### Authority for maintenance of the system:

Title 38, United States Code, section 501.

### PURPOSE(S):

The records and information may be used for ensuring appropriate follow-up care is provided to those who telephone the National Suicide Hotline. In addition, the information will be used for statistical reports for the purpose of evaluating the need for development of further suicide prevention efforts to include education and research. Additionally, the statistical reports will be used to provide information related to suicide to VA officials, congressional members, and the public.

### Routine uses of records maintained in the system, including categories of users and the purposes of such uses:

                        To the extent that records contained in the system include information protected by 45 CFR parts 160 and 164,                         *i.e.,*                         individually identifiable health information, and 38 U.S.C. 7332,                         *i.e.,*                         medical treatment information related to drug abuse, alcoholism or alcohol abuse, sickle cell anemia or infection with the human immunodeficiency virus (HIV), that information cannot be disclosed under a routine use unless there is also specific statutory authority in 38 U.S.C. 7332 and regulatory authority in 45 CFR parts 160 and 164 permitting disclosure.                    

The Suicide Prevention-VA system of record will be routinely used for the following:

1. The record of an individual who is covered by a system of records may be disclosed to a Member of Congress, or a staff person acting for the Member, when the Member or staff person requests the record on behalf of and at the written request of the individual.

2. Disclosure may be made to National Archives and Records Administration (NARA) and the General Services Administration (GSA) in records management inspections conducted under authority of Title 44, Chapter 29, of the United States Code (U.S.C.).

3. Disclosure may be made to other Government agencies in support of data exchanges of electronic medical record information approved by the individual.

4. VA may disclose on its own initiative any information in this system, except the names and home addresses of Veterans and their dependents, that is relevant to a suspected or reasonably imminent violation of law, whether civil, criminal or regulatory in nature and whether arising by general or program statute or by regulation, rule or order issued pursuant thereto, to a Federal, State, local, tribal, or foreign agency charged with the responsibility of investigating or prosecuting such violation, or charged with enforcing or implementing the statute, regulation, rule or order. VA may also disclose on its own initiative the names and addresses of Veterans and their dependents to a Federal agency charged with the responsibility of investigating or prosecuting civil, criminal or regulatory violations of law, or charged with enforcing or implementing the statute, regulation, rule or order issued pursuant thereto.

5. VA may disclose information from this system of records to the Department of Justice (DoJ), either on VA's initiative or in response to DoJ's request for the information, after either VA or DoJ determines that such information is relevant to DoJ's representation of the United States or any of its components in legal proceedings before a court or adjudicative body, provided that, in each case, the agency also determines prior to disclosure that release of the records to the DoJ is a use of the information contained in the records that is compatible with the purpose for which VA collected the records. VA, on its own initiative, may disclose records in this system of records in legal proceedings before a court or administrative body after determining that the disclosure of the records to the court or administrative body is a use of the information contained in the records that is compatible with the purpose for which VA collected the records.

6. Disclosures of relevant information may be made to individuals, organizations, private or public agencies, or other entities with whom VA has a contract or agreement or where there is a subcontract to perform the services as VA may deem practicable for the purposes of laws administered by VA, in order for the contractor or subcontractor to perform the services of the contract or agreement. This routine use includes disclosures by the individual or entity performing the service for VA to any secondary entity or individual to perform an activity that is necessary for individuals, organizations, private or public agencies, or other entities or individuals with whom VA has a contract or agreement to provide the service to VA.

                        7. Disclosure to other Federal agencies may be made to assist such agencies in preventing and detecting possible fraud or abuse by individuals in their operations and programs.                              ( print page 65063)    

8. VA may disclose information to the Equal Employment Opportunity Commission when requested in connection with investigations of alleged or possible discriminatory practices, examination of Federal affirmative employment programs, or for other functions of the Commission as authorized by law or regulation.

9. VA may disclose to the Fair Labor Relations Authority (FLRA) (including its General Counsel) information related to the establishment of jurisdiction, the investigation and resolution of allegations of unfair labor practices, or information in connection with the resolution of exceptions to arbitration awards when a question of material fact is raised; to disclose information in matters properly before the Federal Services Impasse Panel, and to investigate representation petitions and conduct or supervise representation elections.

10. VA may disclose information to officials of the Merit Systems Protection Board (MSPB), or the Office of Special Counsel, when requested in connection with appeals, special studies of the civil service and other merit systems, review of rules and regulations, investigation of alleged or possible prohibited personnel practices, and such other functions, promulgated in 5 U.S.C. 1205 and 1206, or as authorized by law.

11. VA may, on its own initiative, disclose any information or records to appropriate agencies, entities, and persons when (1) VA suspects or has confirmed that the integrity or confidentiality of information in the system of records has been compromised; (2) the Department has determined that as a result of the suspected or confirmed compromise, there is a risk of embarrassment or harm to the reputations of the record subjects, harm to economic or property interests, identity theft or fraud, or harm to the security, confidentiality, or integrity of this system or other systems or programs (whether maintained by the Department or another agency or disclosure is to agencies, entities, or persons whom VA determines are reasonably necessary to assist or carry out the Department's efforts to respond to the suspected or confirmed compromise and prevent, minimize, or remedy such harm. This routine use permits disclosures by the Department to respond to a suspected or confirmed data breach, including the conduct of any risk analysis or provision of credit protection services as provided in 38 U.S.C. 5724, as the terms are defined in 38 U.S.C. 5727.

### Policies and practices for storing, retrieving, accessing, retaining, and disposing of records in the system:

### Storage:

Records are maintained on the Canandaigua VA Medical Center's secure computer server.

### Retrievability:

Records are retrieved by name, social security number or other assigned identifiers of the individuals on whom they are maintained.

### Safeguards:

1. VA will maintain the data in compliance with applicable VA security policy directives that specify the standards that will be applied to protect sensitive personal information. VA's security measures complies with applicable Federal Information Processing Standards (FIPS) issued by the National Institute of Standards and Technology (NIST). Access to VA working and storage areas is restricted to VA employees on a “need-to-know” basis; strict control measures are enforced to ensure that disclosure to these individuals is also based on this same principle. They are required to take annual VA mandatory data privacy and security training. Generally, VA file areas are locked after normal duty hours and the facilities are protected from outside access by the Federal Protective Service or other security personnel.

2. Access to computer rooms at the Canandaigua VA Medical Center is limited by appropriate locking devices and restricted to authorized VA employees and vendor personnel. Peripheral devices are placed in secure areas (areas that are locked or have limited access) or are otherwise protected. Information stored on the Suicide Prevention Database-VA may be accessed by authorized VA employees. Access to file information is controlled at two levels; the systems recognize authorized employees by series of individually unique passwords/codes as a part of each data message, and the employees are limited to only that information in the file which is needed in the performance of their official duties. Information that is downloaded from the Suicide Prevention Database-VA and maintained on personal computers is afforded similar storage and access protections as the data that is maintained in the original files. Access to information stored on automated storage media at other VA locations is controlled by individually unique passwords/codes.

### Retention and disposal:

Paper records and information are maintained and disposed of in accordance with records disposition authority approved by the Archivist of the United States.

### System manager(S) and address:

Official responsible for policies and procedures; VISN 2 Center of Excellence at Canandaigua VA Medical Center (528A5), 400 Fort Hill Avenue, Canandaigua, NY 14424. Officials responsible for the system of records include Craig S. Howard, Director, Canandaigua VA Medical Center; Kerry L. Knox, Ph.D., Director, VISN 2 Center of Excellence; Janet Kemp, RN, Ph.D., Associate Director Education and Training, VISN 2 Center of Excellence.

### Notification procedure:

Individuals who wish to determine whether this system of records contains information about them should contact the Canandaigua VA Medical Center. Inquiries should include the person's full name, social security number, dates of employment, date(s) of contact, and return address.

### Record access procedure:

Individuals seeking information regarding access to and contesting of records in this system may write, call or visit the Canandaigua VA Medical Center.

### Contesting record procedures:

(See Record Access Procedures above.)

### Record source categories:

Information in this system of records is provided by VHA employees.

[FR Doc. 2010-26489 Filed 10-20-10; 8:45 am]

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