Job & Family Services Office of Unemployment Insurance Operations
Eligibility Notice/Refusal to Return to Work Form

Employers: Please use this form to report any suspected instances of individuals improperly receiving unemployment benefits. This may include individuals receiving unemployment benefits who decline offers of suitable work, individuals temporarily laid off from your organization who have declined your request that they return to work, or individuals who have not complied with your organization’s written policies. In addition to completing this form, please also respond to any requests for information you may receive regarding this issue.

Pursuant to Ohio Revised Code Section 4141.28, in order for your report to be considered credible and reliable, it must contain the following: a statement that identifies either a source who has first-hand knowledge of the information or an informant who can identify the source; specific and detailed information that may potentially disqualify the claimant; and the name and address of the source or informant.

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.