Fillable FREEDOM OF INFORMATION ACT (FOIA) REQUEST FORM (Federal Mine Safety & Health Review Commission)

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FREEDOM OF INFORMATION ACT (FOIA) REQUEST FORM (Federal Mine Safety & Health Review Commission)

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FEDERAL MINE SAFETY & HEALTH REVIEW COMMISSION
1331 Pennsylvania Ave., N.W., Ste. 520N, Washington D.C. 20004-1710
Phone: 202/434-9935 • Fax: 202/434-9944
Email: FOIA@FMSHRC.gov
FREEDOM OF INFORMATION ACT (FOIA)
REQUEST FORM
REQUESTER'INFORMATION '
1. Date#Submitted: 2. Requester’s#Name:
Business#Name:
!
3. E-mail:
4. Phone:
5. Address:
6. Specify#Documents/#Information#Requested:
7. Docket#No(s).: 8. Case#Name:
9. Assigned
ALJ:
Choose!an!item.!
10. Deliver#Records#via:
E"ma il
Fax
Office&Viewing
11. On
Appeal:
Choose!an!item.#
12. Requester#Category:
News%Media/%Educational%Institution/%Noncommercial%Scientific%Institution%
Commercial*E ntity
Other
13. Additional#Comments/Petitions:
SUBMIT
NOTE: FMSHRC HAS 20 WORKING DAYS IN WHICH TO NOTIFY YOU OF ITS DETERMINATION. See 5 U.S.C. § 552(a)(6)(A).
FOR'COMMISSION'USE'ONLY'''
1. DATE'REC’D'BY'FMSHRC: 2. DATE'REC’D'BY'FOIA'OFFICE:
different'from'submission'date)
'
3. DATE'PERFECTED:
(If'diff.'from'submission'date)
'
4. REQ.'HELD'IN'ABEYANCE'UNTIL'REC’T'OF:''
☐
'RECORDS''''''
☐
'INFO.'FROM'REQUESTER''''
☐
'FEE'RESOLUTION'''''DATES/DAYS:'Click!here!to!enter!text.
5. TRACK:
☐
SIMPLE'
☐
COMPLEX
☐
EXPEDITED
6. EXP.'PROC.'R EQ.:
☐
GRANTED
☐
DENIED'(IF'SO,'STATE'REASON):
7. F.W.'REQ.:
☐
NOT'ASSESSED'
☐
GRANTED'
☐
DENIED''(IF'SO,'STATE'REASON):
8. DISPOSITION:
a.
☐
'Full'Grant
b.
☐
P
ARTIAL''
G
RANT/'
D
ENIAL''''
1) EXEMPTION:''Choose'an'item.
2) OTHER'REASON:'Choose!an!item.
3) TYPES'OF'RECORDS/INFO.'WITHHELD:
c.
☐
''DENIAL
1) EXEMPTION:''Choose'an'item.
2) OTHER'REASON:'''Choose'an'item.
3) TYPES'OF'RECORDS/INFO.'WITHHELD:
9. NO.'OF'DAYS'TO'INFORM'OF'DECISION: 10. DISPOSITION'DATE: 11.
☐
'CONSULT'A 'AGENCY:
OPINION/RECOMM.:
12. NO.'OF'PAGES'RELEASED:
13. RELEASED'VIA:'''''
☐
'EZMAIL'''''
☐
'FAX'''''
☐
'MAIL'''''
☐
'OFFICE'VIEWING
14. FEE'CAT.:
☐
COM''''
☐
'ED''''''
☐
'OT
15. FEE'CHARGED:'''''
☐
'NO
☐
YES'$
16. FOIA'OFFICER:'''
☐
'SDB''''
☐
'TW''''
☐
'EJ
17. TIME'WORKED:
APPEAL'
Appeal!Date:!! Appeal!Disposition!Date:!!
Disposition!Type:! ☐ Affirm!CFO ☐ Partially!Affirm/Reverse!CFO ☐ Reverse!CFO
www.fmshrc.gov'
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FREEDOM OF INFORMATION ACT (FOIA) REQUEST FORM (Federal Mine Safety & Health Review Commission)

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Completed 4 October 2021

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