Employee Authorization for the City of Sacramento's Use and Disclosure of Vaccination Status

Consistent with California’s Confidentiality of Medical Information Act, I (employee) authorize the City of Sacramento and its agents to use and disclose information regarding my COVID-19 vaccination and/or testing status for legitimate, non-discriminatory business purposes where my vaccination status is necessary for the City of Sacramento and its agents to make work-related decisions authorized by or in order to comply with federal, state, or local law, regulation, rule, ordinance,  resolution, or policy that takes a person’s vaccination status into account.

I also authorize the City of Sacramento and its agents to use and disclose my COVID-19 vaccination and/or testing status for the purposes provided under the Cal/OSHA COVID-19 Regulations. (8 C.C.R. §§ 3205-3205.4)

This authorization is limited to information regarding my COVID-19 vaccination and/or testing status.

I acknowledge that the disclosure of my vaccination status is or may be impliedly or constructively disclosed by submitting to weekly COVID-19 testing.

I  understand that the City of Sacramento and its agents may be required by law to disclose my vaccination status to certain federal, state and/or local agencies, and I authorize them to do so, to the extent required by law.

I understand that I have the right to receive a copy of this authorization. Upon submission of my authorization, I will be provided a link to a copy of my authorization. In the alternative, I may submit a written request to the Department of Human Resources, and the City of Sacramento will provide me with a copy of my authorization.

I authorize the limited uses and disclosures of my medical information as described above for the purposes listed above.

I understand that this authorization shall be in effect until December 31, 2023.

eCAPS ID

Please enter your full eCAPS ID (7 digits, numeric only, starting with 2-3 zeroes)
ex: 0012345

Employees must submit their primary vaccine information and their booster information separately. This means that an employee submitting their vaccine and booster information for the first time must submit this form twice; the first time to submit the primary vaccine information and the second time to submit their booster information.

Employees who have previously submitted their vaccine information and are now submitting their booster information need to submit this form only once. It is not necessary to resubmit their vaccine information if it is already on file.