Public Records Act Request Form
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1
2State 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
Party/Representing a party
Due date
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:
Yes
No
Is Request for Purposes of Pre-Employment Screening?
(If yes, DWC shall send notification letter to injured worker)
For Request for Personal Information of 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
Authorized Agent:
Knox Attorney Service, Inc./ Knox Services LLC.
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Parent category: Legal