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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