Refusal to Work - Fraud Report

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Employer - Business Name

Employer - Contact Name

Employer - Contact Email

Employer - Contact Phone

Employer - ID Number

Employee - Last 4 of SSN

Employee - Scheduled Return to Work Date

Date Work Was Offered

Date Work Was to Start (Per Offer)

How Was Work Offered

In-Person

Phone - Call

Phone - Text

Email

Written Letter

Other

Name of person who offered work

What was the job title of position offered?

What did Claimant provide a reason for why they could not return to work?

What date did Claimant provide this response?

Was the type of work offered similar to work done previously?

Yes

No

What was the type of work offered?

Full-time

Part-time

Other

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