Reporting Refusal of Return to 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:

Reason for Separation:

Date recall/offer of work 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)

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)