Employee Record Request

EMPLOYEE RECORD REQUEST

Requestor Information

Self (Employee)    Current Supervisor    HR Representative    Legal Counsel    Third-Party/Authorized Representative

Employee Identification

Employment Dates: From to

Records Requested

Indicate the records requested (select all that apply):

Personnel file    Attendance/time records    Performance evaluations    Disciplinary records

Payroll / wage records    Benefits enrollment / claims    Medical or ADA records    I-9 and employment eligibility documents

Tax forms (W-2, 1095, etc.)    Workers' compensation files    Other (describe below)

Date Range for Requested Records: From to

Purpose of Request

Employment verification    Personal review by employee    Legal proceeding or counsel review

Benefits administration    Other

Identity Verification

To protect employee privacy, proof of identity is required. Indicate type of identification provided:

State ID / Driver's License    Passport    Birth Certificate    Other

Delivery Method & Fees

Preferred delivery method (select one or more):

Mail to address on file / provided address    Email to requestor email    Office pickup (ID required)

Fees: The organization may charge a reasonable fee for search, retrieval and copying of personnel records. By signing below, the requester agrees to pay assessed fees.

Employee Information (Employment History)

Provide primary employment history entries below for identity verification and record location.

Dates Employed: to

Dates Employed: to

Education

References (for verification)

Provide three professional references.

Legal Disclosures & Certifications

At-Will Employment: Nothing in this request form alters the at-will employment relationship between the employer and employee where applicable. This request concerns the release of records only and does not constitute a change in employment status.

Equal Opportunity: The organization complies with all applicable equal employment opportunity laws. Records released under this request will be handled in accordance with applicable nondiscrimination requirements and privacy protections.

Applicant Certification: I certify that the information provided in this Employee Record Request is true and complete to the best of my knowledge. I understand that knowingly submitting false information may result in denial of the request and may subject me to legal consequences.

Authorization to Contact Previous Employers and Conduct Background Checks: By signing this form, the employee (or the employee's authorized representative) authorizes the employer to contact past employers and to conduct reasonable background checks to verify identity and locate requested records, to the extent permitted by law.

I certify that the information provided is true and that I am authorized to request these records under the relationship indicated above.

Acknowledgment & Authorization to Release Records

I hereby authorize the employer to release the records specified on this form to the requestor named above. This authorization is limited to the records and date ranges specified and does not authorize release of unrelated confidential medical or privileged legal communications unless expressly indicated. I understand that I may revoke this authorization in writing at any time, except to the extent action has already been taken in reliance on it.

I further acknowledge that copies of personnel records may include materials prepared by others and that certain records may be withheld if protected by law (for example, certain medical information or third-party confidential information). The employer will notify the requester in writing of any such redactions or withholdings and the legal basis for them.

HR Use Only

Applicant Certification & Authorization

I certify under penalty of perjury that I am the person named above or the lawful authorized representative of the person named above. I authorize the release of the requested records to the requestor named on this form for the purposes indicated. I understand that this authorization is voluntary and may be revoked in writing except to the extent records have already been released in reliance on this authorization.

By signing below, I also authorize the employer to contact prior employers and third parties as reasonably necessary to locate and verify the records requested, and to charge fees consistent with the employer's record release policy.

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