New York Codes, Rules and Regulations › Title 21 - Miscellaneous › Chapter XXV - Committee On Open Government › Part 1402 - Privacy Impact Statement › Section 1402.5 - Form of privacy impact statement

Current through Register Vol. 46, No. 28, July 10, 2024
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)
............................................................................................................................................................
_____________.._____________........................................................................................................................................................
_____________.._____________.................................................................................................................................................
_____________
				  .._____________.......................................................................................................................................
_____________.._____________.................................................................................................................................................
_____________
				  .._____________...............................................................................................................................................