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Michigan Department of Energy, Labor & Economic Growth
Michigan Occupational Safety & Health Administration (MIOSHA)
P.O. Box 30649
Lansing, MI 48909-8144
Telephone: (517) 322-1295 Fax: (517) 322-1505
Request for Public Records
Authority Michigan Freedom of Information Act, 1976 PA 442, as amended
Name
Telephone Number (include Area Code)
Firm / Organization
Fax Number (Include Area Code)
Address
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(if you would like to receive a confirmation email of your submission, you must include your email address)
Describe the public record as specifically as possible, such as complete employer name and address, and/or name of injured party, and date of injury (if applicable): (Please provide file number if known)
I wish to obtain
copy(ies) of the record(s).
Signature
Date
CONSENT TO EXTENSION OF TIME ON REQUEST FOR PUBLIC RECORDS
I have requested a copy of or access to records pursuant to the Michigan Freedom of Information Act, 1976 PA 442, as amended. I understand that the public body must respond to the request within five (5) business days after receiving it, except that the public body may take an extension for an additional ten (10) days. However, I hereby agree and consent to extending the time for the public body to respond to my request until.
Signature
Date
DELEG is an equal opportunity employer/program.
Auxiliary aids, services and other reasonable accommodations are available upon request to individuals with disabilities.