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

1. Name of Agency Subdivision of agency maintaining

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system of records

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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).............................................................................................................................................................