I. Requesting Your Records
A. Your Rights — Your Records
The Information Practices Act, effective July 1, 1978, was enacted to protect your right of privacy.
Under the Act, release by a state agency of personal or confidential information about you is
restricted. You are allowed to see and receive copies of any personal information pertaining to you
which is contained in files maintained by California State Agencies. You are not, however, permitted
access to confidential information.
Requests for all items of information on the reverse side (except public information) of this form are
made under the provisions of the Information Practices Act of 1977. (Civil Code 1798.32)
The information you provided on this form may be shared with the Office of Information Practices at
the State Personnel Board.
B. How to See Your Personal Information Record
You may request to see or receive copies of personal information pertaining to you in Department of
Social Services (DSS) files by contacting the licensing office that maintains information on you.
Before DSS will release personal information to you, you must complete spaces on the reverse side of
this form which relate to verification of your identity. Completing other spaces is not mandatory.
However, other information you provide will be used to locate your records. If you do not provide
enough information, DSS may be unable to locate the items you have requested. Few DSS records
are maintained more than five years.
C. Penalties for False Requests
Penalties under this Act provide that any person who willfully requests or obtains any record
containing personal or confidential information from an agency under false pretenses shall be guilty of
a misdemeanor and fined not more than five thousand dollars ($5,000) or imprisoned not more than
one year or both.
II. If You Think Your Records are Incorrect
If you believe that personal information pertaining to you is incorrect, you have the right to request in
writing that the record be amended. Include in your request for amendment all facts and documentation
which support the request. Within 30 days of receipt of your amendment request, you will be informed
that the corrections have been made or of the Department’s refusal to amend the record and the reason
for refusal.
If you disagree with the Department’s refusal to amend the record, you may request a review by the
Department’s Office of the Chief Counsel. Within 30 days of receipt of such a request, unless extended
for good cause, you will be notified of the final determination.
If the final review determination upholds the refusal to amend the record, you may file a statement of
reasonable length setting forth your reasons for disagreement with the determination. The Department
will then clearly note the disputed portion of the record and will make available, to any person or agency
to whom the disputed record has been or is disclosed, copies of your statement and the Department’s
reasons for not amending the record.
