Report refusal of work, recall or interview

EAN :

Employers Name:

Employer contact/person filling out the form:

Employer phone number:

Claimant Name:

Last four of Claimant SSN (if not known, enter “1111”) :

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:

• 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):