Employee Work Refusal Documentation Indicates required information Employer Information Employer Name Employer Account Number Employer Point of Contact Name Employer Point of Contact Phone (xxx-xxx-xxxx) Claimant Information First Name Middle Initial Last Name Claimant SSN (xxx-xx-xxxx) Date of Job Offer (MM/DD/YYYY) Job Offer Method Select Verbal Written Position Offered Work Schedule Were the wages, hours, or conditions of the work offer same as past? Select Yes No Rate of Pay Reason of Refusal Select At High Risk Diagnosed with COVID Quarantined by health care provider due to exposure to COVID Family member with COVID Child's school or daycare closed Safety Reduced Hours Other Refusal Other Description Save Cancel