Form CDPH8689 "Agreement by Employees/Contractor to Comply With Confidentiality Requirements" - California

What Is Form CDPH8689?

This is a legal form that was released by the California Department of Public Health - a government authority operating within California. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on October 1, 2012;
  • The latest edition provided by the California Department of Public Health;
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  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form CDPH8689 by clicking the link below or browse more documents and templates provided by the California Department of Public Health.

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Download Form CDPH8689 "Agreement by Employees/Contractor to Comply With Confidentiality Requirements" - California

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State of California—Health and Human Services Agency
California Department of Public Health
Office of AIDS
Agreement by Employee/Contractor to Comply with Confidentiality Requirements
Summary of Statutes Pertaining to Confidential Public Health Records and Penalties for Disclosure
All HIV/AIDS case reports and any information collected or maintained in the course of surveillance-related
activities that may directly or indirectly identify an individual are considered confidential public health record(s)
under California Health and Safety Code (HSC), Section 121035(c) and must be handled with the utmost
confidentiality. Furthermore, HSC §121025(a) prohibits the disclosure of HIV/AIDS-related public health records
that contain any personally identifying information to any third party, unless authorized by law for public health
purposes,
or
by
the
written
consent
of
the
individual
identified
in
the
record
or
his/her
guardian/conservator. Except as permitted by law, any person who negligently discloses information contained
in a confidential public health record to a third party is subject to a civil penalty of up to $5,000 plus court
costs, as provided in HSC §121025(e)(1). Any person who willfully or maliciously discloses the content of a
public health record, except as authorized by law, is subject to a civil penalty of $5,000-$25,000 plus
court costs as provided by HSC §121025(e)(2). Any willful, malicious, or negligent disclosure of information
contained in a public health record in violation of state law that results in economic, bodily, or psychological
harm to the person named in the record is a misdemeanor, punishable by imprisonment for a period of up to
one year and/or a fine of up to $25,000 plus court costs (HSC §121025(e)(3)). Any person who is guilty of a
confidentiality infringement of the foregoing type may be sued by the injured party and shall be personally
liable for all actual damages incurred for economic, bodily, or psychological harm as a result of the breach
(HSC §121025(e)(4)). Each disclosure in violation of California law is a separate, actionable offense (HSC
§121025(e)(5)).
Because an assurance of case confidentiality is the foremost concern of the California Department of Public
Health, Office of AIDS (CDPH/OA), any actual or potential breach of confidentiality shall be immediately
reported. In the event of any suspected breach, staff shall immediately notify the director or supervisor of the
local health department’s HIV/AIDS surveillance unit who in turn shall notify the CDPH/OA Surveillance
Section Chief or designee. CDPH/OA, in conjunction with the local health department and the local health
officer shall promptly investigate the suspected breach. Any evidence of an actual breach shall be reported
to the law enforcement agency that has jurisdiction.
Employee Confidentiality Pledge
I recognize that in carrying out my assigned duties, I may obtain access to private information about
persons diagnosed with HIV or AIDS that was provided under an assurance of confidentiality. I understand that
I am prohibited from disclosing or otherwise releasing any personally identifying information, either directly or
indirectly, about any individual named in any HIV/AIDS confidential public health record. Should I be
responsible for any breach of confidentiality, I understand that civil and/or criminal penalties may be brought
against me. I acknowledge that my responsibility to ensure the privacy of protected health information
contained in any electronic records, paper documents, or verbal communications to which I may gain access
shall not expire, even after my employment or affiliation with the Department has terminated.
By my signature, I acknowledge that I have read, understand, and agree to comply with the terms and
conditions above.
___________________________________
________________________________
____________
Employee name (print)
Employee Signature
Date
_____________________________
_
________________________________
____________
Supervisor name (print)
Supervisor Signature
Date
___________________________________
Name of Employer
P L E A S E R E T A I N A C O P Y O F T H I S D O C U M E N T F O R Y O U R R E C O R D S.
CDPH 8 6 8 9 (Revised 10/12)
State of California—Health and Human Services Agency
California Department of Public Health
Office of AIDS
Agreement by Employee/Contractor to Comply with Confidentiality Requirements
Summary of Statutes Pertaining to Confidential Public Health Records and Penalties for Disclosure
All HIV/AIDS case reports and any information collected or maintained in the course of surveillance-related
activities that may directly or indirectly identify an individual are considered confidential public health record(s)
under California Health and Safety Code (HSC), Section 121035(c) and must be handled with the utmost
confidentiality. Furthermore, HSC §121025(a) prohibits the disclosure of HIV/AIDS-related public health records
that contain any personally identifying information to any third party, unless authorized by law for public health
purposes,
or
by
the
written
consent
of
the
individual
identified
in
the
record
or
his/her
guardian/conservator. Except as permitted by law, any person who negligently discloses information contained
in a confidential public health record to a third party is subject to a civil penalty of up to $5,000 plus court
costs, as provided in HSC §121025(e)(1). Any person who willfully or maliciously discloses the content of a
public health record, except as authorized by law, is subject to a civil penalty of $5,000-$25,000 plus
court costs as provided by HSC §121025(e)(2). Any willful, malicious, or negligent disclosure of information
contained in a public health record in violation of state law that results in economic, bodily, or psychological
harm to the person named in the record is a misdemeanor, punishable by imprisonment for a period of up to
one year and/or a fine of up to $25,000 plus court costs (HSC §121025(e)(3)). Any person who is guilty of a
confidentiality infringement of the foregoing type may be sued by the injured party and shall be personally
liable for all actual damages incurred for economic, bodily, or psychological harm as a result of the breach
(HSC §121025(e)(4)). Each disclosure in violation of California law is a separate, actionable offense (HSC
§121025(e)(5)).
Because an assurance of case confidentiality is the foremost concern of the California Department of Public
Health, Office of AIDS (CDPH/OA), any actual or potential breach of confidentiality shall be immediately
reported. In the event of any suspected breach, staff shall immediately notify the director or supervisor of the
local health department’s HIV/AIDS surveillance unit who in turn shall notify the CDPH/OA Surveillance
Section Chief or designee. CDPH/OA, in conjunction with the local health department and the local health
officer shall promptly investigate the suspected breach. Any evidence of an actual breach shall be reported
to the law enforcement agency that has jurisdiction.
Employee Confidentiality Pledge
I recognize that in carrying out my assigned duties, I may obtain access to private information about
persons diagnosed with HIV or AIDS that was provided under an assurance of confidentiality. I understand that
I am prohibited from disclosing or otherwise releasing any personally identifying information, either directly or
indirectly, about any individual named in any HIV/AIDS confidential public health record. Should I be
responsible for any breach of confidentiality, I understand that civil and/or criminal penalties may be brought
against me. I acknowledge that my responsibility to ensure the privacy of protected health information
contained in any electronic records, paper documents, or verbal communications to which I may gain access
shall not expire, even after my employment or affiliation with the Department has terminated.
By my signature, I acknowledge that I have read, understand, and agree to comply with the terms and
conditions above.
___________________________________
________________________________
____________
Employee name (print)
Employee Signature
Date
_____________________________
_
________________________________
____________
Supervisor name (print)
Supervisor Signature
Date
___________________________________
Name of Employer
P L E A S E R E T A I N A C O P Y O F T H I S D O C U M E N T F O R Y O U R R E C O R D S.
CDPH 8 6 8 9 (Revised 10/12)