Reset Form REQUEST FOR PUBLIC RECORD State Form 53811 (R / 5-15) WORKER'S COMPENSATION BOARD OF INDIANA Date (month, day, year) Name Firm / organization Address (number and street) Telephone number (business, home, etc.) City E-mail Address State ZIP Code Identify in detail the records/documents that you are requesting: (Use additional pages if necessary.) Mail or Fax your request to: Worker's Compensation Board of Indiana Indiana Government Center South, Room W196 402 West Washington Street Indianapolis, Indiana 46204 Telephone Number: (317) 232-3808 Fax Number: (317) 233-5493 Online services available at www.in.gov/wcb. Requests for Disclosure of Public Records: Guidelines General Rule: All records of a public agency are public records and must be disclosed upon request, unless the request falls under an exception provided by the Access to Public Records Act (APRA) of Indiana (codified in Indiana Code 5-143). A public agency must state that a record falls under an identified APRA exception in order to withhold a specific record. Pursuant to IC 22-3-43(a), the accident reports and reports of attending physicians are private records of the Board. As such, they will only be released when the request is submitted with a signed authorization from the employee, employer, or their legal representative. All requests: The APRA requires that all requests for inspection or copying of public records must identify those records with "reasonable particularity." This means a request must include a description of a record of enough detail to allow agency staff to locate and produce the requested record. Response by Agency: The APRA requires a public agency to respond to requests within a specified time. Important Note: This response does not mean that the requested record must be produced at that time. First, the agency must, at a minimum, acknowledge receipt of a request. Second, the record(s), if disclosable, must be produced within a "reasonable time" after the request is received. Records that do not exist: Under the APRA, an agency is not required to create any record(s) in response to a request. An agency is only required to disclose existing records. Copy fees: Public agencies may charge fees for copies. No fees may be charged for inspection. American LegalNet, Inc. www.FormsWorkFlow.com