Reporting Refusal of Work – COVID-19

EAN :

Employers Name:

Employer contact/person filling out the form:

Employer phone number:

Claimant Name:

Last four of Claimant SSN:

Date of Separation (if applicable):

Reason for Separation (if applicable):

Date the recall OR offer of work OR scheduled interview OR request for interview took place:

First date work was expected to commence:

Outcome of the offer of work – multiple choice:

• No response/unable to contact claimant:
• Claimant responded and refused work (please provide comment in subsequent field)
• Claimant was contacted for interview and refused
• Claimant was scheduled for interview and was a no show

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? (if applicable) Yes No

If No, please provide details of how job conditions changed (new location, new job duties, different pay, different hours)