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Employer contact/person filling out the form:
Employer phone number:
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:
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 No, please provide details of how job conditions changed (new location, new job duties, different pay, different hours)
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Employers / Businesses
Bureau of Employment Services
Bureau of Labor Standards
Bureau of Rehabilitation Services
Bureau of Unemployment Compensation
Center for Workforce Research and Information
The Department of Labor is an equal opportunity provider. Auxiliary aids and services are available to individuals with disabilities upon request.