Workplace Incident Records Release Authorization
Authorize the release of your workplace incident records. Please complete all sections below.
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Date of Incident (if known)
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Brief Description of the Incident or Records to be Released
*
Recipient Name or Organization (who will receive the records)
*
Recipient Email or Contact Information
Signature
*
Date Signed
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit Authorization
Submit Authorization
Should be Empty: