URLThis field is for validation purposes and should be left unchanged.Name(Required) First Middle Last Please note you must be a California resident to request information based on the California Consumer Privacy Act.Address(Required) Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Email Enter Email Confirm Email Phone(Required)Please describe in what capacity or context you have interacted with us to date in which you may have provided personal information to us:(Required) Employee Job Applicant Independent Contractor or Consultant Website User App User Individual Customer (non-entity) Service Provider, Vendor or Supplier Other Would you like to access Employee Workplace Injury or Illness Records? Yes No Otherplease specifyType of Request(Required)Right to KnowRight to AccessRight to DeleteRight to CorrectRight to Opt-OutRight to LimitType of Request(Required)Right to KnowRight to AccessRight to DeleteRight to CorrectRight to Opt-OutRight to LimitAccess Request - Employee Workplace Injury or Illness Records Categories of personal information collected from or about me since 1/1/2022. Categories of sources from which the personal information was collected. Business purpose for which the personal information was used. Categories of third parties to which the personal information was disclosed since 1/1/2022. Please provide me with the specific pieces of personal information collected from or about me since 1/1/2022.Request to CorrectPlease correct personal information you have collected from me. Please enter a short description of the personal information you believe is incorrect, using the box below.Please enter the correct personal information in box below.Are you sure you want us to correct the personal information that you have identified? Yes No Request to Limit Use and Disclosure of Sensitive Personal InformationPlease limit your use and/or disclosure of my sensitive personal information to only those purposes expressly prescribed by the California Privacy Rights Act. Yes No Request for DeletionPlease delete all personal information that you have collected from me. Are you sure you want us to permanently delete all your personal information that we have collected from you? Yes No I do not want my personal information to be sold. Please cease and refrain from selling my personal information. I do not want my personal information to be shared with a third party for cross-context behavioral advertising purposes. Please cease and refrain from sharing my personal information for such purposes. This request has been submitted through an agent on my behalf:(Required) Yes No Agent’s Name:(Required)This agent has been authorized in writing to submit this request on my behalf: Yes No
