Kentucky Career Center - Work Refusal Reporting

Claimant Information

Claimant Name *

Address Line1

Address Line2

City

State

Zip

Phone #

Claimant Birth Date

(in MM/DD/YYYY format)

Social Security #

Employer Information

Employer Name *

(where work was offered)

Address Line1

Address Line2

City

State

Zip

Phone #

Representative *

(who made the offer)

Work Offer Date

(date the offer of work was made in MM/DD/YYYY format)

Job Begin Date

(date the job was to begin in MM/DD/YYYY format)

Rate of Pay

Education Required

Work Type Offered

Job Type

Permanent Temporary

Hours of job offered

Drug Test Required?

Yes No
If "Yes", did Claimant Pass or Fail

Job Refuse Reason

Any other information you feel is important for us to know to complete our investigation:

(max. 4000 chars)

Information Submitted by

Full Name *

Phone #