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Job & Family Services Office of Unemployment Insurance Operations
Eligibility Notice/Refusal to Return to Work Form
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Pursuant to Ohio Revised Code Section 4141.28, in order for an eligibility notice to be considered valid, the notice must contain: a statement that identifies either a source who has first-hand knowledge of the information or an informant who can identify the source; provide specific and detailed information that may potentially disqualify the claimant; provide the name and address of the source or informant; and appear to be reliable and credible.

Please note: This web page is a secure document. Any information you see or enter is encrypted for privacy during transmission and will not be easily read by a third party.

Please fill out the following with specificity:

* Denotes Required Field

*
Your Name (first and last):
 
 
Your Address:
 
*
Your Email Address:
 
 
Employer Name (if the source is an employer):
 
 
Employer FEIN (if the source is an employer):
 
*
Claimant/Employee Name (first and last):
 
 
Claimant ID or Last Four Digits of Claimant SSN:
 
*
Do you have first-hand knowledge of the information/allegation contained in this Eligibility Notice?
If no, please identify a source who does have first-hand knowledge of the information/allegation contained in this Eligibility Notice:
 
Source's Name (first and last):
 
 
Source's Address:
 
 
Source's Email Address:
 
 
Source's Phone Number:
 
*
Please provide specific and detailed information about the eligibility issue and/or refusal to return to work:
 
 
If this is a Refusal to Return to Work notice, please fill out the following (if not, you may disregard):
 
Was your business deemed "essential," requiring your employees to continue to work?
 
If no, what date did you reopen?
 [None] Select a Date Delete the Date  
 
Date that work was offered to the employee
 [None] Select a Date Delete the Date  
 
Date of refusal of work
 [None] Select a Date Delete the Date  
 
Was the work (job duties, hours/shift, pay) the same as pre-COVID-19?
 
If no, please explain the change:
 
 
Does your business maintain health and safety standards recommended by the Ohio Department of Health during COVID-19?
 
If no, please explain:
 
 
Did you offer the employee the option to telework?
 
Please provide any additional details you would like the agency to consider:
 
 
 

We will review the necessary files and records in light of the information you have provided to determine the most appropriate action.