Public Records Act Request Form (DLSE) Form. This is a California form and can be use in DLSE Forms Workers Comp.
Tags: Public Records Act Request Form (DLSE), California Workers Comp, DLSE Forms
Edmund G. Brown Jr., Governor S TATE OF C ALIFORNIA DEPARTMENT OF INDUSTRIAL RELATIONS DIVISION OF LABOR STANDARDS ENFORCEMENT Headquarters Office P. O. Box 420603 San Francisco, CA 94142 (415) 703 ‐4810 (415) 703 ‐4807 fax PUBLIC RECORDS ACT REQUEST FORM Division HQ Use Only INTAKE CASE NO. To expedite your request and to eliminate opportunities for error, please fill out this form completely with as much detail as possible and identify specifically the records you are requesting. Requests should reasonably describe identifiable records prepared, owned, used or retained by the Division of Labor Standards Enforcement. The intake staff is available to assist you in identifying the records in the control of the Division based on your description. The Division is not required by law to create a new record or list from an existing record. Please note that if you are requesting the opportunity to inspect records stored at this office, the Division must be given time to locate and review documents that are responsive to your request in order to comply with the provisions of the Public Records Act. You will, therefore, be requested to make an appointment to return at a later date to view the documents. You will be charged the direct cost of duplication for any documents received over ten (10) pages. Documents will not be copied until payment has been received. Please carefully read the back of this form for information on copying costs and other pertinent information. REQUESTER INFORMATION Name: Date: Company: Mailing Address: State/Zip Code: City: Fax number: Phone number: Email address: Preferred method of contact in the event of questions: REQUESTED RECORDS Time period covering documents requested: ___ I wish to inspect the requested records, where applicable, and do not want copies produced at this time. ___ I would like copies of the requested records and I understand that I will be contacted with a count of the number of pages to be copied and their cost prior to copying. I understand and agree that I will be required to make payment for the copying costs prior to the documents requested being copied. Signature of Requester PRA Request Form Rev. 8/2011 1 American LegalNet, Inc. www.FormsWorkFlow.com It is the policy of the Division of Labor Standards Enforcement (“DLSE”) that public records are open to inspection at all times during the DLSE’s office hours. DLSE office hours are Monday through Friday, 8 a.m. to 5 p.m. Any reasonably segregable portion of a record shall be available for inspection by any person requesting the record after deletion of the portions that are exempted by law. It is also the policy of the DLSE that except for public records exempt from disclosure by express provisions of law, a request for a copy of reasonably-described identifiable records shall be made available with minimal delay to the requesting party. An exact copy shall be provided unless impracticable to do so. Requests must be for records in the possession of, prepared, owned, used or retained by the DLSE (Gov. Code Sec. 6252(e)) and requests must be for clearly identifiable records. If necessary, DLSE staff will assist the requesting party in making a request that describes reasonably identifiable records (Gov. Code Sec. 6253.1). Copies will not be provided if disclosure is exempt in accordance with state law or would constitute an unreasonable burden on the operation of the DLSE. You will be notified by mail within ten (10) days: • • • • • Whether the DLSE requires an extension of time to determine whether it has records responsive to your request Whether the DLSE has records responsive to your request Whether the DLSE has records responsive to your request but which are exempt from disclosure and the reasons for exemption Whether the DLSE has records responsive to your request and the page count and cost of copying the records Based on the page count, the time required to copy the documents requested. Copying of documents responsive to your request will be completed as soon as possible. If your request is to review documents rather than receive copies, the DLSE will make an appointment at the time of presentation of your request for a future date reasonable to allow the DLSE time to gather the documents and review them for compliance with the provisions of the Public Records Act. The charge for copies of any specifically described and identified public records not exempt from disclosure is $.19 per page for copied documents, except there will be no charge for less than ten (10) pages. Paper copies generated from computer database programs, diskette or microfiche are $.19 per page. Copied hearing CDs or audio tapes are One Dollar ($1.00) each. Records stored by the DLSE in electronic format will be provided in the same electronic format when requested by any person. Direct costs incurred by the DLSE in providing certain electronic data, including direct costs of redacting confidential information or information not otherwise subject to disclosure, shall be paid by the recipient. The DLSE is not required to produce records in an electronic format when the requested records are not available in electronic format at the time of the request. The Public Records unit in DLSE Headquarters will provide an invoice for charges due. These charges are due and payable upon receipt of the invoice. Upon remittance of the invoice amount, the records requested will be copied and sent to the Requester. For further clarification, please refer to the California Public Records Act (California Gov. Code Sec. 6250 et seq.) and the DLSE’s website at www.dir.ca.gov/dlse PRA Request Form Rev. 8/2011 2 American LegalNet, Inc. www.FormsWorkFlow.com