Disclosure
The
Genetic Information Nondiscrimination Act of 2008 (GINA) prohibits employers and other entities covered by GINA Title II from requesting, or requiring, genetic information of an individual or family member of the individual, except as specifically allowed by this law. To comply with this law, please DO NOT provide any genetic information when responding to this request for medical information. “Genetic information,” as defined by GINA, includes an individual’s family medical history, the results of an individual’s or family member’s genetic tests, the fact that an individual or an individual’s family member sought or received genetic services, and genetic information of a fetus carried by an individual or an individual’s family member or an embryo lawfully held by an individual or family member receiving assistive reproductive services.
PRIVACY DISCLOSURES (California Civil Code § 1798.17)
The following information regarding the medical questionnaire you are completing is provided in compliance with the notice requirements of California Civil Code § 1798.17.
Personal Information Notice
Personal Information Notice Pursuant to the
Federal Privacy Act (P.L. 93-579) and the
Information Practices Act of 1977 (Civil Code Sections 1798, et seq.), notice is hereby given for the request of personal information by this form. The requested personal information is voluntary. The principal purpose of the voluntary information is to facilitate the processing of this form. The failure to provide all or part of the requested information may delay processing of this form. No disclosure of personal information will be made unless permissible under
Article 6 of the Information Practice Act of 1977 (Civil Code Section 1798.24). Each individual has the right, upon request and proper identification, to inspect all personal information in any record maintained on the individual by an identifying particular. Direct any inquiries to
calfire.cpo@fire.ca.gov.
Information Requested By:
The California Department of Forestry and Fire Protection (CAL FIRE)
Medical Assessment Unit
Agency Official Responsible for CAL FIRE Medical Assessment Unit:
CAL FIRE Medical Consultant
Medical Assessment Unit
P. O. Box 980370,
West Sacramento, CA 95798
Authority for maintenance of CAL FIRE's Medical Assessment Unit records:
Government Code Section 18931
Purpose of Collection:
The information furnished will be used to evaluate medical fitness to carry out the duties of the position applied for, or the current position held with CAL FIRE, without endangering the health and safety of the candidate, employee, or others.
Providing Information:
Completion of this questionnaire is mandatory. Medical clearance is required prior to employment in State service. Annual medical clearance is mandatory for existing employees who are required to have an annual medical evaluation through CAL FIRE’s Respiratory Protection Program (RPP).
Effects of Not Providing Information or Misrepresentation:
Applicants, seasonal employees and retired annuitants: Please be aware that by signing and submitting your completed questionnaire, you are certifying that you have provided true and complete information concerning your fitness. (Any misrepresentation or material omission may be cause for dismissal.)
Access to Information:
Medical records will be maintained in a confidential manner. These records will not be disclosed without your prior consent unless otherwise required by law. These records may be reviewed by you by contacting the Medical Assessment Unit at CALFIREMedAssessUnit@fire.ca.gov. You will be required to sign a release form after confirming your identity.
Reasonable Accommodation:
If you believe you may require reasonable accommodations in order to satisfactorily perform the duties of the position you hold or for which you are applying, contact the Medical Assessment Unit at CALFIREMedAssessUnit@fire.ca.gov or (916) 894-9570.
Password Requirements:
Password cannot be the same as a password in a known data breach from other websites. e.g.
HaveIBeenPwned.com
