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EAN :
Employers Name:
Employer contact/person filling out the form:
Employer phone number:
Claimant Name:
Last four of Claimant SSN:
Date of Separation:
Reason for Separation:
Date recall/offer of work took place:
First date work was expected to commence:
Outcome of the offer of work – choose one:
Reason given for the refusal:
Date of the refusal (if no contact, please leave blank):
Was the work offered under the same conditions as the job vacated by the claimant as a result of COVID-19? Yes No
If No, please provide details of how job conditions changed (new location, new job duties, different pay, different hours)