[Federal Register Volume 67, Number 115 (Friday, June 14, 2002)]
[Notices]
[Pages 40937-40941]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 02-15008]


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DEPARTMENT OF HEALTH AND HUMAN SERVICES

Centers for Medicare & Medicaid Services


Privacy Act of 1974; Report of Modified or Altered System

AGENCY: Department of Health and Human Services (HHS), Centers for 
Medicare & Medicaid Services (CMS) (formerly the Health Care Financing 
Administration).

[[Page 40938]]


ACTION: Notice of modified or altered system of records (SOR).

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SUMMARY: In accordance with the requirements of the Privacy Act of 
1974, we are proposing to modify or alter an SOR, ``Employee Building 
Pass File (EBP) System, System No. 09-70-3002.'' We propose to delete 
published routine uses number 1 authorizing disclosures to the Federal 
Protection Services (FPS), number 2 authorizing disclosures to 
``management officials inquiring about an individual's authorization to 
enter Federal occupied buildings,'' number 3 authorizing disclosures to 
contractors, and an unnumbered routine use authorizing disclosure to 
the Social Security Administration (SSA). Disclosures allowed by 
routine use number 1, and to the SSA will be covered by proposed 
routine use number 2 to permit release of information to ``another 
Federal agency.'' Routine use number 2 is being deleted because it is 
not clear what ``management officials'' are being identified and who 
should receive information referred to in routine use number 2. 
Disclosures previously allowed by the former routine use number 2 will 
now be covered by the proposed routine use number 2 and by exceptions 
to the Privacy Act. Disclosures previously allowed by routine use 
number 3 will now be covered by proposed routine use number 1.
    The security classification previously reported as ``None'' will be 
modified to reflect that the data in this system is considered to be 
``Level Three Privacy Act Sensitive.'' We are modifying the language in 
the remaining routine uses to provide clarity to CMS's intention to 
disclose individual-specific information contained in this system. The 
routine uses will then be prioritized and reordered according to their 
proposed usage. We will also take the opportunity to update any 
sections of the system that were affected by the recent reorganization 
and to update language in the administrative sections to correspond 
with language used in other CMS SORs.
    The primary purpose of the SOR is to issue and control United 
States Government building passes issued to all CMS employees and non-
CMS employees who require continuous access to CMS buildings in 
Baltimore and other CMS and HHS facilities. Information retrieved from 
this SOR will be used to: support regulatory and policy functions 
performed within the Agency or by a contractor or consultant, assist 
other Federal agencies with activities related to this system, support 
constituent requests made to congressional representatives, and support 
litigation involving the Agency. We have provided background 
information about the modified system in the ``Supplementary 
Information'' section below. Although the Privacy Act requires only 
that CMS provide an opportunity for interested persons to comment on 
the proposed routine uses, CMS invites comments on all portions of this 
notice. See EFFECTIVE DATES section for comment period.

 EFFECTIVE DATES: CMS filed a modified or altered system report with 
the Chair of the House Committee on Government Reform and Oversight, 
the Chair of the Senate Committee on Governmental Affairs, and the 
Administrator, Office of Information and Regulatory Affairs, Office of 
Management and Budget (OMB) on May 22, 2002. To ensure that all parties 
have adequate time in which to comment, the modified or altered SOR, 
including routine uses, will become effective 40 days from the 
publication of the notice, or from the date it was submitted to OMB and 
the Congress, whichever is later, unless CMS receives comments that 
require alterations to this notice.

ADDRESSES: The public should address comments to: Director, Division of 
Data Liaison and Distribution (DDLD), CMS, Room N2-04-27, 7500 Security 
Boulevard, Baltimore, Maryland 21244-1850. Comments received will be 
available for review at this location, by appointment, during regular 
business hours, Monday through Friday from 9 a.m.-3 p.m., eastern 
daylight time.

FOR FURTHER INFORMATION CONTACT: Marcia Levin, Division of Facilities 
Management Services, Administrative Services Group, CMS, SLL-11-18, 
7500 Security Boulevard, Baltimore, Maryland, 21244-1850. The telephone 
number is 410-786-7840.

SUPPLEMENTARY INFORMATION:

I. Description of the Modified System

A. Background

    In 1981, CMS established this system to carry out the directives 
authorizing Federal workers and other authorized personnel be issued 
United States Government identification cards. Notice of this system, 
``Employee Building Pass File (EBP) System, System No. 09-70-3002,'' 
was published in the Federal Register (FR) at 46 FR 3524 (Jan. 15, 
1981), and modified at 61 FR 6645 (added unnumbered SSA routine use).

B. Statutory and Regulatory Basis for System

    Authority for maintenance of this system of records is given under 
section 486(c) of Title 40, United States Code (USC) and Title 41, Code 
of Federal Regulations (CFR), Chapter 101-20.302.

II. Collection and Maintenance of Data in the System

A. Scope of the Data Collected

    The system contain information on Federal employees, contractors 
and consultants, Government Services Administration employees, and 
contract guards working in CMS's central office complex in Baltimore, 
Maryland, and other CMS and HHS Federal buildings. The system contain 
name of the employee or other authorized individuals, social security 
number, identification card number, building/work location, phone 
number, position, title, grade, supervisor's name and telephone number.

B. Agency Policies, Procedures, and Restrictions on the Routine Use

    The Privacy Act permits us to disclose information without an 
individual's consent if the information is to be used for a purpose 
that is compatible with the purpose(s) for which the information was 
collected. Any such disclosure of data is known as a ``routine use.'' 
The government will only release EBP information that can be associated 
with an individual as provided for under ``Section III. Proposed 
Routine Use Disclosures of Data in the System.'' Both identifiable and 
non-identifiable data may be disclosed under a routine use.
    We will only disclose the minimum personal data necessary to 
achieve the purpose of EBP. CMS has the following policies and 
procedures concerning disclosures of information that will be 
maintained in the system. Disclosure of information from the SOR will 
be approved only to the extent necessary to accomplish the purpose of 
the disclosure and only after CMS:
    1. Determines that the use or disclosure is consistent with the 
reason data is being collected; e.g., to issue and control United 
States Government building passes issued to all CMS employees and non-
CMS employees who require continuous access to CMS buildings in 
Baltimore and other CMS and HHS facilities.
    2. Determines that:
    a. The purpose for which the disclosure is to be made can only be 
accomplished if the record is provided in individually identifiable 
form;
    b. The purpose for which the disclosure is to be made is of 
sufficient importance to warrant the effect and/or risk on the privacy 
of the individual that additional exposure of the record might bring; 
and

[[Page 40939]]

    c. There is a strong probability that the proposed use of the data 
would in fact accomplish the stated purpose(s).
    3. Requires the information recipient to:
    a. Establish administrative, technical, and physical safeguards to 
prevent unauthorized use of disclosure of the record;
    b. Remove or destroy at the earliest time all patient-identifiable 
information; and
    c. Agree to not use or disclose the information for any purpose 
other than the stated purpose under which the information was 
disclosed.
    4. Determines that the data are valid and reliable.

III. Proposed Routine Use Disclosures of Data in the System

A. Entities Who May Receive Disclosures Under Routine Use

    These routine uses specify circumstances, in addition to those 
provided by statute in the Privacy Act of 1974, under which CMS may 
release information from the EBP without the consent of the individual 
to whom such information pertains. Each proposed disclosure of 
information under these routine uses will be evaluated to ensure that 
the disclosure is legally permissible, including but not limited to 
ensuring that the purpose of the disclosure is compatible with the 
purpose for which the information was collected. We are proposing to 
establish or modify the following routine use disclosures of 
information maintained in the system:
    1. To agency contractors, or consultants who have been engaged by 
the Agency to assist in accomplishment of a CMS function relating to 
the purposes for this SOR and who need to have access to the records in 
order to assist CMS.
    We contemplate disclosing information under this routine use only 
in situations in which CMS may enter into a contractual or similar 
agreement with a third party to assist in accomplishing a CMS function 
relating to purposes for this SOR.
    CMS occasionally contracts out certain of its functions when doing 
so would contribute to effective and efficient operations. CMS must be 
able to give a contractor or consultant whatever information is 
necessary for the contractor or consultant to fulfill its duties. In 
these situations, safeguards are provided in the contract prohibiting 
the contractor or consultant from using or disclosing the information 
for any purpose other than that described in the contract and requires 
the contractor or consultant to return or destroy all information at 
the completion of the contract.
    2. To assist other Federal agencies with activities related to this 
system and who need to have access to the records in order to perform 
the activity.
    The FPS may require EBP data to enable them to assist in inquiries 
about an individual's authorization to enter CMS's central office 
complex in Baltimore, Maryland and other CMS and HHS Federal buildings
    We contemplate disclosing information under this routine use only 
in situations in which CMS may enter into a contractual or similar 
agreement with another Federal agency to assist in accomplishing CMS 
functions relating to purposes for this SOR.
    3. To Members of Congress or to congressional staff members in 
response to an inquiry of the congressional office made at the written 
request of the constituent about whom the record is maintained.
    Federal employees and other individuals who may be identified in 
this system sometimes request the help of a Member of Congress in 
resolving an issue relating to a matter before CMS. The Member of 
Congress then writes CMS, and CMS must be able to give sufficient 
information to be responsive to the inquiry.
    4. To the Department of Justice (DOJ), court or adjudicatory body 
when:
    a. The agency or any component thereof, or
    b. Any employee of the agency in his or her official capacity, or
    c. Any employee of the agency in his or her individual capacity 
where the DOJ agreed to represent the employee, or
    d. The United States Government is a party to litigation or has an 
interest in such litigation, and by careful review, CMS determines that 
the records are both relevant and necessary to the litigation.
    Whenever CMS is involved in litigation, or occasionally when 
another party is involved in litigation and CMS's policies or 
operations could be affected by the outcome of the litigation, CMS 
would be able to disclose information to the DOJ, court or adjudicatory 
body involved.

B. Additional Circumstances Affecting Routine Use Disclosures

    This SOR contains Protected Health Information as defined by HHS 
regulation ``Standards for Privacy of Individually Identifiable Health 
Information'' (45 CFR parts 160 and 164, 65 FR 82462 (12-28-00), as 
amended by 66 FR 12434 (2-26-01)). Disclosures of Protected Health 
Information authorized by these routine uses may only be made if, and 
as, permitted or required by the ``Standards for Privacy of 
Individually Identifiable Health Information''.
    In addition, our policy will be to prohibit release even of non-
identifiable data, except pursuant to one of the routine uses, if there 
is a possibility that an individual can be identified through implicit 
deduction based on small cell sizes (instances where the patient 
population is so small that individuals who are familiar with the 
enrollees could, because of the small size, use this information to 
deduce the identity of the beneficiary).

IV. Safeguards

A. Administrative Safeguards

    The EBP system will conform to applicable law and policy governing 
the privacy and security of Federal automated information systems. 
These include but are not limited to: the Privacy Act of 1984, Computer 
Security Act of 1987, the Paperwork Reduction Act of 1995, the Clinger-
Cohen Act of 1996, and the Office and Management and Budget (OMB) 
Circular A-130, Appendix III, ``Security of Federal Automated 
Information Resources.'' CMS has prepared a comprehensive system 
security plan as required by OMB Circular A-130, Appendix III. This 
plan conforms fully to guidance issued by the National Institute for 
Standards and Technology (NIST) in NIST Special Publication 800-18, 
``Guide for Developing Security Plans for Information Technology 
Systems. Paragraphs A-C of this section highlight some of the specific 
methods that CMS is using to ensure the security of this system and the 
information within it.
    Authorized users: Personnel having access to the system have been 
trained in Privacy Act and systems security requirements. Employees and 
contractors who maintain records in the system are instructed not to 
release any data until the intended recipient agrees to implement 
appropriate administrative, technical, procedural, and physical 
safeguards sufficient to protect the confidentiality of the data and to 
prevent unauthorized access to the data. In addition, CMS is monitoring 
the authorized users to ensure against excessive or unauthorized use. 
Records are used in a designated work area or workstation and the 
system location is attended at all times during working hours.
    To insure security of the data, the proper level of class user is 
assigned for each individual user as determined at the Agency level. 
This prevents

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unauthorized users from accessing and modifying critical data. The 
system database configuration includes five classes of database users:
     Database Administrator class owns the database objects; 
e.g., tables, triggers, indexes, stored procedures, packages, and has 
database administration privileges to these objects;
     Quality Control Administrator class has read and write 
access to key fields in the database;
     Quality Indicator Report Generator class has read-only 
access to all fields and tables;
     Policy Research class has query access to tables, but are 
not allowed to access confidential patient identification information; 
and
     Submitter class has read and write access to database 
objects, but no database administration privileges.

B. Physical Safeguards

    All server sites have implemented the following minimum 
requirements to assist in reducing the exposure of computer equipment 
and thus achieve an optimum level of protection and security for the 
EBP system:
    Access to all servers is controlled, with access limited to only 
those support personnel with a demonstrated need for access. Servers 
are to be kept in a locked room accessible only by specified management 
and system support personnel. Each server requires a specific log-on 
process. All entrance doors are identified and marked. A log is kept of 
all personnel who were issued a security card, key and/or combination 
that grants access to the room housing the server, and all visitors are 
escorted while in this room. All servers are housed in an area where 
appropriate environmental security controls are implemented, which 
include measures implemented to mitigate damage to Automated 
Information System resources caused by fire, electricity, water and 
inadequate climate controls.
    Protection applied to the workstations, servers and databases 
include:
     User Log on--Authentication is performed by the Primary 
Domain Controller/Backup Domain Controller of the log-on domain.
     Workstation Names--Workstation naming conventions may be 
defined and implemented at the Agency level.
     Hours of Operation--May be restricted by Windows NT. When 
activated all applicable processes will automatically shut down at a 
specific time and not be permitted to resume until the predetermined 
time. The appropriate hours of operation are determined and implemented 
at the Agency level.
     Inactivity Log-out--Access to the NT workstation is 
automatically logged out after a specified period of inactivity.
     Warnings--Legal notices and security warnings display on 
all servers and workstations.
     Remote Access Services (RAS)--Windows NT RAS security 
handles resource access control. Access to NT resources is controlled 
for remote users in the same manner as local users, by utilizing 
Windows NT file and sharing permissions. Dial-in access can be granted 
or restricted on a user-by-user basis through the Windows NT RAS 
administration tool.

C. Procedural Safeguards

    All automated systems must comply with Federal laws, guidance, and 
policies for information systems security as stated previously in this 
section. Each automated information system should ensure a level of 
security commensurate with the level of sensitivity of the data, risk, 
and magnitude of the harm that may result from the loss, misuse, 
disclosure, or modification of the information contained in the system.

V. Effect of the Modified System on Individual Rights

    CMS proposes to establish this system in accordance with the 
principles and requirements of the Privacy Act and will collect, use, 
and disseminate information only as prescribed therein. We will only 
disclose the minimum personal data necessary to achieve the purpose of 
EBP.
    Disclosure of information from the SOR will be approved only to the 
extent necessary to accomplish the purpose of the disclosure. CMS has 
assigned a higher level of security clearance for the information in 
this system to provide added security and protection of data in this 
system.
    CMS will take precautionary measures to minimize the risks of 
unauthorized access to the records and the potential harm to individual 
privacy or other personal or property rights. CMS will collect only 
that information necessary to perform the system's functions. In 
addition, CMS will make disclosure from the proposed system only with 
consent of the subject individual, or his/her legal representative, or 
in accordance with an applicable exception provision of the Privacy 
Act.
    CMS, therefore, does not anticipate an unfavorable effect on 
individual privacy as a result of the disclosure of information 
relating to individuals.

    Dated: May 22, 2002.
Thomas A. Scully,
Administrator, Centers for Medicare & Medicaid Services.
09-70-3002

System Name:
    Employee Building Pass File (EBP) System, HHS/CMS/OICS.

Security Classification:
    Level Three Privacy Act Sensitive.

System Location:
    Centers for Medicare & Medicaid Services (CMS), 7500 Security 
Boulevard, North Building, First Floor (magnetic media), and South 
Building, Lower Level, Baltimore, Maryland 21244-1850.

Categories of Individuals Covered by the System:
    The identified individual includes Federal employees, contractors 
and consultants, and Government Services Administration (GSA) 
employees, and contract guards working in CMS's central office complex 
in Baltimore, Maryland.

Categories of Records in the System:
    The system includes the employees' or other individual's name, 
social security number, identification card number, building/work 
location, phone number, position, title, grade, and supervisor's name 
and telephone number.

Authority for Maintenance of the System:
    Authority for maintenance of this system of records is given under 
section 486(c) of Title 40, United States Code (USC) and Title 41, Code 
of Federal Regulations (CFR), Chapter 101-20.302.

Purpose(s) of the System:
    The primary purpose of the system of records is to issue and 
control United States Government building passes issued to all CMS 
employees and non-CMS employees who require continuous access to CMS 
buildings in Baltimore and other CMS and HHS facilities. Information 
retrieved from this system of records will be used to: support 
regulatory and policy functions performed within the Agency or by a 
contractor or consultant, assist other Federal agencies with activities 
related to this system, support constituent requests made to a 
congressional representative, and support litigation involving the 
Agency.

Routine Uses of Records Maintained in the System, Including Categories 
or Users and the Purposes of Such Uses:
    The Privacy Act allows us to disclose information without an 
individual's

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consent if the information is to be used for a purpose that is 
compatible with the purpose(s) for which the information was collected. 
Any such compatible use of data is known as a ``routine use.'' The 
proposed routine use in this system meets the compatibility requirement 
of the Privacy Act.
    This SOR contains Protected Health Information as defined by HHS 
regulation ``Standards for Privacy of Individually Identifiable Health 
Information'' (45 CFR parts 160 and 164, 65 FR 82462 (12-28-00), as 
amended by 66 FR 12434 (2-26-01)). Disclosures of Protected Health 
Information authorized by these routine uses may only be made if, and 
as, permitted or required by the ``Standards for Privacy of 
Individually Identifiable Health Information''.
    In addition, our policy will be to prohibit release even of non-
identifiable data, except pursuant to one of the routine uses, if there 
is a possibility that an individual can be identified through implicit 
deduction based on small cell sizes (instances where the patient 
population is so small that individuals who are familiar with the 
enrollees could, because of the small size, use this information to 
deduce the identity of the beneficiary). We are proposing to establish 
or modify he following routine use disclosures of information which 
will be maintained in the system:
    1. To agency contractors, or consultants who have been engaged by 
the Agency to assist in accomplishment of a CMS function relating to 
the purposes for this SOR and who need to have access to the records in 
order to assist CMS.
    2. To assist other Federal agencies with activities related to this 
system and who need to have access to the records in order to perform 
the activity.
    3. To Member of Congress or to a congressional staff member in 
response to an inquiry of the congressional office made at the written 
request of the constituent about whom the record is maintained.
    4. To the Department of Justice (DOJ), court or adjudicatory body 
when:
    a. The agency or any component thereof, or
    b. Any employee of the agency in his or her official capacity, or
    c. Any employee of the agency in his or her individual capacity 
where the DOJ has agreed to represent the employee, or
    d. The United States Government is a party to litigation or has an 
interest in such litigation, and by careful review, CMS determines that 
the records are both relevant and necessary to the litigation.

Policies and Practices for Storing, Retrieving, Accessing, Retaining, 
and Disposing of Records in the System:
Storage:
    All records are stored on paper and magnetic media.

Retrievability:
    Magnetic media records are retrieved by the name of the employees 
or other authorized individuals. Paper records are retrieved 
alphabetically by name.

Safeguards:
    CMS has safeguards for authorized users and monitors such users to 
ensure against excessive or unauthorized use. Personnel having access 
to the system have been trained in the Privacy Act and systems security 
requirements. Employees who maintain records in the system are 
instructed not to release any data until the intended recipient agrees 
to implement appropriate administrative, technical, procedural, and 
physical safeguards sufficient to protect the confidentiality of the 
data and to prevent unauthorized access to the data.
    In addition, CMS has physical safeguards in place to reduce the 
exposure of computer equipment and thus achieve an optimum level of 
protection and security for the EBP system. For computerized records, 
safeguards have been established in accordance with HHS standards and 
National Institute of Standards and Technology guidelines, e.g., 
security codes will be used, limiting access to authorized personnel. 
System securities are established in accordance with HHS, Information 
Resource Management (IRM) Circular 10, Automated Information 
Systems Security Program, CMS Automated Information Systems (AIS) 
Guide, Systems Securities Policies, and OMB Circular No. A-130 
(revised), Appendix III.

Retention and Disposal:
    Records are retained for up to 3 years following expiration of an 
individual's authority to enter designated federal facilities. When an 
individual is no longer authorized, information is deleted from 
magnetic media immediately.

System Manager and Address:
    Director, Division of Facilities Management Services, 
Administrative Services Group, Office of Internal Customer Support, 
CMS, Room SLL-11-08, 7500 Security Boulevard, Baltimore, Maryland 
21244-1850.

Notification Procedure:
    For purpose of access, the subject individual should write to the 
system manager who will require the system name, identification card 
number, address, and for verification purposes, the subject 
individual's name (woman's maiden name, if applicable), and social 
security number (SSN). Furnishing the SSN is voluntary, but it may make 
searching for a record easier and prevent delay.

Record Access Procedure:
    For purpose of access, use the same procedures outlined in 
Notification Procedures above. Requestors should also reasonably 
specify the record contents being sought. (These procedures are in 
accordance with Department regulation 45 CFR 5b.5(a)(2)).

Contesting Record Procedures:
    The subject individual should contact the system manager named 
above, and reasonably identify the record and specify the information 
to be contested. State the corrective action sought and the reasons for 
the correction with supporting justification. (These procedures are in 
accordance with Department regulation 45 CFR 5b.7).

Record Source Categories:
    CMS obtains information in this system from the individuals who are 
covered by this system.

Systems Exempted from Certain Provisions of the Act:
    None.
[FR Doc. 02-15008 Filed 6-13-02; 8:45 am]
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