DEPARTMENT OF LABOR & INDUSTRY
OFFICE OF UNEMPLOYMENT COMPENSATION BENEFITS POLICY
EMPLOYER QUESTIONNAIRE
REFUSAL SUITABLE WORK
Submit the completed form, along with any additional documentation, within seven (7) days of the
refusal of a job offer or referral. (All elds marked in red must be completed prior to submission.)
Claimant’s Name: Social Security No.: XXX-XX-
Employer’s Name: UC Acct No.:
Contact Person: Title:
Employer’s Address: Email:
Telephone No.:
Temporary Stafng Agency? Yes
□ No □ Fax Number:
In order for the department to determine the claimant’s eligibility for unemployment
compensation and to protect your employer account, please answer the following questions:
1. Did the claimant refuse to accept a referral to employment? Yes
□ No □
If Yes:
(a) In what manner was the referral made?
(b) Who made the referral?
(c) Please explain the type of employment to which the claimant was referred.
2. Did you offer the claimant a specic job that the claimant refused? Yes
□ No □
If Yes:
(a) Has the claimant ever worked for you? Yes
□ No □
(b) On what date was the job offer made?
(c) How was the job offer made?
(d) Who made the job offer?
3. What reason did the claimant give for refusing the job offer or referral to employment?
4. What were the duties of the job that was offered/referred?
(a) What was the job’s rate of pay? per Temporary
□ Permanent □
(b) What were the scheduled working hours? Full time □ Part time □
(c) Where was the job located?
(d) Please describe any unusual requirements or conditions of work
(e) When was the job scheduled to start?
(f) If the job was temporary, when was it scheduled to end?
I certify that all information I have provided is true and correct.
Signature Title Date
Auxiliary aids and services are available upon request to individuals with disabilities.
UC-1921(W) REV 10-18
Equal Opportunity Employer/Program
