California > Workers Comp > General
Public Records Act Request Form - California
| Public Records Act Request Form Form. This is a California form and can be used in General Workers Comp . |
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State of California Division of Workers' Compensation Public Records Act Request Form Routine requests should be made to your local district office. Click here for local district office locations. Date received ________________ Due date ________________ Party/Representing a party Not a party (Response Due: Immediately or within 10 days from date of request) Requester Information [Voluntary unless seeking personal or individually identifiable information] Name Company DWC Authorization Number [Copy, Legal & Investigative Services] Representing Business Address Alternative Address City, State, ZIP Code Telephone (business) Fax E-Mail Description of Records Requested/Initial Contact with Requesting Party: Inspection Copying WCAB File No.: Injured Workers Name: Other: Is Request for Purposes of Pre-Employment Screening? (If yes, DWC shall send notification letter to injured worker) Yes No For Requests for Personal Information or Individually Identifiable Information, state the purpose for which the information will be used and provide proof of identity and address. Name of DWC Employee-Initial Contact: If other than routine request fax to: Stephanie Leach, Statewide Records Coordinator at (916) 322-3470 Public Records Act Request Form July 2006 American LegalNet, Inc. www.USCourtForms.com
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