Michigan Department of Licensing and Regulatory Affairs 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

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Firm / Organization Fax Number (Include Area Code)

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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

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