PERSONNEL RECORD COPY REQUEST FORM

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					                  PERSONNEL RECORD COPY REQUEST FORM
                                     Phone: 617-582-0100
                                      Fax: 617-582-0165

Under Chapter 149, Section 52C or the M.G.L., I hereby request a copy of my personnel record
from Brigham and Women’s Hospital.

                PLEASE ALLOW 5 BUSINESS DAYS FOR PROCESSING

Check one:

    Current Employee                          Former Employee


Name (please print):______________________________________________________

Employee ID #: __________________________________________________________

Social Security Number: __________________________________________________

Date of Request: ____/______/________

Time of Request: ________:_________ AM/PM

Signature:_______________________________________________________________

*Cost is $0.25 per page.


For HR Use Only:

Date Rec’d in HR: ________/__________/_________

Date Completed: ______/_______/_______

Total pages copied: _________

Cost: $____________      Check Received(Y/N) _______       Cash Received(Y/N) ______

Consultant: _____________________________________________________________

Request Filled By: _______________________________________________________
11/11/2008