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.

First and Last Name

No Dashes, Hyphens or Spaces

Position/Title

Did the employee have experience with this type of work?*

Insert Dollar Amount ($)

Days of the Week / Hours of the Day

Please provide additional details:

First and Last Name

I (Employer Representative), certify that the information provided is true and correct to the best of my knowledge.


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