Request for Access to Records

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Please mail or fax the completed form.
Freedom of Information and Fax Mail
Protection of Privacy Office 604.279.7401 Freedom of Information and Protection of Privacy Office
Phone 604.279.8171 Legal Services Division
Toll-free 1.866.266.9405 WorkSafeBC
PO Box 2310 Stn Terminal
Vancouver BC V6B 3W5
General information
You may make a request for access to records without using this form, provided you do so in writing.
Personal information contained on this Request for Access to Records form is collected under the Freedom of
Information and Protection of Privacy Act and will be used only for the purposes of responding to your request.
Your name (please print clearly)

Last name First name Middle initial Optional

Miss Ms. Mrs.
Mr. Other

Your organization name (if applicable)

Your mailing address

Street, apartment number, PO box, RR number

City/town Province/country Postal code

Your telephone/fax number(s)

Day phone number (include area code) Alternate phone number (include area code) Fax number (include area code)

Details of requested information

Describe the records you are requesting — be as specific as possible, as this will Note: Please specify any
assist the request process (attach a separate sheet if the space below is not sufficient) reference, claim, or file number(s)

Are you requesting access to another If yes, please attach as appropriate:

person’s personal information? (a) That person’s signed consent for disclosure, or
Yes No (b) Proof of authority to act on that person’s behalf
Preferred method of access to records Your signature Date signed (yyyy-mm-dd)
Examine record, or Receive copy

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