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| I,
(Full name of Employee or Representative) hereby request access to (my)
Medical Records
and/or Exposure Records as it/they relate(s) to the following conditions of (my/his/her) employment or place of employment: |
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| I understand I will be provided access to the requested record(s) within a reasonable time, place, and manner, but in no event later than fifteen (15) days after the date of this request. I further understand that whenever a record has been provided previously without cost, I may be charged reasonable, non-discriminatory administrative costs for additional copies. |
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Employee's
Last Name:
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Employee's
First Name:
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CSUN ID #: |
| Job Title: | Department: | Telephone: |
| Supervisor's Name: | Accident Location: |
| Employee Signature or Signature of Representative: _________________________________________________ Date: ___________________ |