Public Records Request {07-6122}

STATE OF ALASKA DIVISION OF WORKERS' COMPENSATION PUBLIC RECORDS REQUEST Pursuant to Alaska Statute 40.25 and Alaska Regulation 2 AAC 96.100, a public record of the Division of Workers' Compensation and the Alaska Workers' Compensation Board is subject to public inspection. Medical or rehabilitation records held by the Division or Board are not public records open to inspection. For copies of workers' compensation case files, use the Request for Release of Information Form, 07-6121. To obtain records from the Division or the Board, you are required to 1) Provide the information requested below. An incomplete form will delay processing your request. 2) Pay the applicable reproduction fee. Requestor's Printed Name: Firm Name (If Applicable): Requestor's Mailing Address: Requestor's Phone Number: Requestor's Email: Are you a party, or representing a party, involved in litigation with the Division of Workers' Compensation, the Alaska Workers' Compensation Board, or the State of Alaska? Yes No Fax Number: If yes, based on the nature of the request, you may be required to submit your request in accordance with applicable court rules. Description of Public Records Sought. Describe the public records sought in sufficient detail to enable the Division to identify and locate the appropriate records: Requestor's Signature: Date: Send Completed Form To the Division of Workers' Compensation at one of these offices: ANCHORAGE 3301 Eagle Street, Suite 304 Anchorage, AK 99503 (907) 269-4980 (phone) (907) 269-4975 (fax) workerscomp@alaska.gov Form 07-6122 (Rev 05/2012) FAIRBANKS 675 Seventh Avenue, Station K Fairbanks, AK 99701-4531 (907) 451-2889 (phone) (907) 451-2928 (fax) workerscomp@alaska.gov JUNEAU P.O. Box 115512 Juneau, AK 99811-5512 (907) 465-2790 (phone) (907) 465-2797 (fax) workerscomp@alaska.gov American LegalNet, Inc. www.FormsWorkFlow.com THIS SIDE FOR DIVISION USE ONLY This public records request must be entered into the Division's Freedom of Information (FOI) log. The Division must respond to the FOI request within 10 working days of receipt and payment of the reproduction fee (if applicable). Date Request Received: Return Receipt Sent with Request & Acknowledged? Date Requested Records Were Sent: List additional information or fees needed before the requested records are produced: Yes No Date Request for Additional Information was Sent: Person Requesting Additional Information: Date Request was Resubmitted: If requested records were not produced, reason why FOI request was denied: Person Authorizing Denial of Records Request: Date Denial was Sent: Records Copied By: Mailed On: Picked Up On: Bill Prepared By: Bill Mailed On: (Date) by (Staff Name) (Date) (Date) by by (Staff Name) (Name) FEE SCHEDULE (Check or Money Order Only) The Division may waive the reproduction fee if it determines that producing the requested records is in the public interest. Paper Copies: $.35 per page Microfilm Copies: $.75 per page Microfiche Copies: $50.00 per fiche Certification of Copies: $5.00 per certification Hearing Recording Copies: $10.00 per recording Data Query: $80.00/hour, $20.00 (1/4 hour) minimum Form 07-6122 (Rev 05/2012) American LegalNet, Inc. www.FormsWorkFlow.com