Department of Energy Privacy Impact Assessment (PIA) Guidance is provided in the template. See DOE Order 206.1, Department of Energy Privacy Program, Appendix A, Privacy Impact Assessments, for requirements and additional guidance for conducting a PIA: Please complete form and return via email to Privacy@hq.doe.gov No hand-written submissions will be accepted. This template may not be modified. MODULE I PRIVACY NEEDS ASSESSMENT – Date Date the assessment was completed. The official list of Departmental Elements can be accessed at Departmental Please also list the site location of the system with as much specificity as possible Element & Site (e.g. DOE Headquarters, Forrestal, 1G-053 server room). Enter the name of the information system. If the system is part of an enclave or Name of Information general support system (GSS), please include the name of the enclave or GSS along System or IT Project with the name identifying the application or subsystem being assessed. Enter the project unique identifier used for capital planning (eCPIC) or the contract Exhibit Project UID name that provides the funding for the system. New PIA Please indicate whether this is a new PIA or an update to an existing PIA. List the name of the PIA being updated. Update Contact Information Name, Title Phone, Email System Owners are Departmental Element officials responsible for monitoring the Use the full phone number and information systems under their purview to email. For example ensure compliance with this Order. System System Owner Owners are responsible for the overall (202) 555-1212 procurement, development, integration, John.doe@hq.doe.gov maintenance, secure operation, and safeguarding of Privacy information including PII for their information system(s). System
Department of Energy Privacy Impact Assessment (PIA) Guidance is provided in the template. See DOE Order 206.1, Department of Energy Privacy Program, Appendix A, Privacy Impact Assessments, for requirements and additional guidance for conducting a PIA: Please complete form and return via email to Privacy@hq.doe.gov No hand-written submissions will be accepted. This template may not be modified. MODULE I – PRIVACY NEEDS ASSESSMENT Date Date the assessment was completed. Departmental Element & Site The official list of Departmental Elements can be accessed at Please also list the site location of the system with as much specificity as possible (e.g. DOE Headquarters, Forrestal, 1G-053 server room). Name of Information System or IT Project Enter the name of the information system. If the system is part of an enclave or general support system (GSS), please include the name of the enclave or GSS along with the name identifying the application or subsystem being assessed. Exhibit Project UID Enter the project unique identifier used for capital planning (eCPIC) or the contract name that provides the funding for the system. New PIA Update Please indicate whether this is a new PIA or an update to an existing PIA. List the name of the PIA being updated. Name, Title Contact Information Phone, Email System Owner System Owners are Departmental Element officials responsible for monitoring the information systems under their purview to ensure compliance with this Order. System Owners are responsible for the overall procurement, development, integration, maintenance, secure operation, and safeguarding of Privacy information including PII for their information system(s). System Use the full phone number and email. For example (202) 555-1212 John.doe@hq.doe.gov
pia_template_june_2014.docx