Workers' Compensation Program
Department of Employee Relations
Information and Privacy

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The Minnesota Government Data Practice Act (MN Statutes 13.01-13.88) requires that you be informed of the following.

1. The data your agency or the Department of Employee Relations collects from you, for the First Report of Injury, or during the course of investigating or managing your claim, is private data and will be collected for the purpose of assisting the Department of Employee Relations in making an initial determination of whether your injury is work related; in determining any initial and continued eligibility to receive benefits; and in computing the amount of payment you may be entitled to receive, should it be determined that your injury is work related. The data is also collected for the purpose of reporting to the Department of Labor & Industry any injury which wholly or partly incapacitates an employee from performing labor or services for more than three calendar days. This report is required by law.
   
   
2. You are NOT legally required to provide this information to us.
   
   
3. If you do not provide certain data to us, however, we may be unable to complete the investigation of your claim for benefits and determine eligibility for benefits. Your refusal to provide information may cause your claim to be denied, or if you are eligible for benefits, your payment may be delayed. If you provide data to us, it will assist us to in making an appropriate determination of liability and benefit eligibility.
   
   
4. The information you provide will be available to:

• those within your agency or the Department of Employee Relations whose jobs reasonably require access, such as worker's compensation coordinators or claims management specialists;
• the Department of Revenue for use in enforcing Minnesota income tax and property tax refund law;
• the Department of Labor and Industry for completion of legally required reports; and
• the Departments of Labor and Industry, Jobs and Training and Revenue who are authorized to share information regarding the employment status of individuals including payroll, withholding and income tax information.
  

5. You may review all the non-investigative claim information maintained by the Department of Employee Relations, Employee Insurance Division. There is no charge for reviewing this information, however, there is a small copy charge if you request copies.

I HAVE READ THE NOTICE REGARDING INFORMATION AND PRIVACY AS SET FORTH ABOVE.

Signature _______________________________________

Date __________________________