Work Refusal Reporting Form

Claimant Information
   (in MM/DD/YYYY format)
Employer Information
(where work was offered)
(who made the offer)
   (date the offer of work was made in MM/DD/YYYY format)
   (date the job was to begin in MM/DD/YYYY format)
Job Type
Drug Test Required?
If "Yes", did Claimant     or  
 Any other information you feel is important for us to know to complete our investigation:
(max. 4000 chars)
Information Submitted by