Request For Public Records Form
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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 ________________
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:
Is Request for Purposes of Pre-Employment Screening?
Yes
No
(If yes, DWC shall send notification letter to injured worker)
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:
DWC_PRA@dir.ca.gov
Public Records Act Request Form
May 2011
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Parent category: Business