(By Employee)

I, (name of employee), hereby request the opportunity to review the following records contained in my employee file (specify):

I agree to inspect these records only in the presence of my supervisor or (specify other individual).  I agree not to make copies of these documents but will only make independent notes of these records after my review of same.

I will not remove any contents or documents from my file without my supervisor's approval and, if said approval is given, I will report the documents removed and promptly return these documents in good condition.

I have been advised and understand that although XYZ Employer is granting this request, the Company may remove confidential information from my file before my review, including certain medical information, preemployment references, contents of privileged investigations and EEO data.

I acknowledge that if I breach any of the representations contained hereinabove, I may be disciplined leading up to or including immediate discharge by XYZ Employer.

EMPLOYER AUTHORIZATION

Request Approved:
Request Denied: (Specify Reason)
By:
Title:
Department:
Documents Reviewed:
Date of Review:
Comments:


Employee Statements Regarding Accuracy of Information in file: