Public Records Act Request Form | Pdf Fpdf Doc Docx | California

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Public Records Act Request Form | Pdf Fpdf Doc Docx | California

Public Records Act Request Form

This is a California form that can be used for General within Workers Comp.

Alternate TextLast updated: 3/1/2017

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State of California Division of Workers' Compensation Request for Public Records 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: WCAB File No.: Injured Workers Name: Other: Inspection Copying 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 email: Public Records Act Request Form May 2011 American LegalNet, Inc.

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