Employer Reported Job Refusal
Use this employer form to report individuals who have:
• Refused an offer of work,
• Failed to report to work after hire, -OR-
• Have chosen not to return to work when recalled.
Name of Individual
*
First and Last Name
SSN (if known):
No Dashes, Hyphens or Spaces
Date Of Birth (if known):
Phone Number (if known):
Type of Work Offered
*
Position/Title
Date of Job Offer
*
Date Employee Was To Start Work
*
Did the employee have experience with this type of work?
*
No Prior Experience
Minimal Prior Experience
Experienced
Rate of Pay Offered
*
Insert Dollar Amount ($)
Shift(s) Offered
Days of the Week / Hours of the Day
Date Employee Refused Offer of Work
*
Reason(s) the Employee Refused Work
*
Please provide additional details:
Employer/Business Name
*
Employer BIN
*
Name of Employer Representative
*
First and Last Name
Position/Title
*
Employer Phone #
*
Self-Certification
*
I (Employer Representative), certify that the information provided is true and correct to the best of my knowledge.
Send me a copy of my responses
Email address
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