Free Public Records Request Form - California


File Size: 482.5 kB
Pages: 1
File Format: PDF
State: California
Category: Workers Compensation
Author: Stephanie Leach
Word Count: 174 Words, 1,258 Characters
Page Size: Letter (8 1/2" x 11")
URL

http://www.dir.ca.gov/dwc/FORMS/DWC_PublicRecordsRequestForm.pdf

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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: 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 email: [email protected] fax: 916-322-3470 Public Records Act Request Form October 2006