Form Adj016Fe PDF Details

Form Adj016Fe is a form used to report the status of an employee's leave. The form is used to provide information on the types of leave taken by an employee, the duration of the leave, and any other necessary information. This form should be completed by both the employer and the employee. In many cases, using this form can help ensure that employees are taking appropriate leave and that employers are properly recording this information. Completing this form can also help protect employers in the event of any legal issues related to leaves of absence.

Form NameForm Adj016Fe
Form Length1 pages
Fillable fields0
Avg. time to fill out15 sec
Other namesRefusalofWorkQu estionnaire_ADJ 016FE refusal to work questionnaire form

Form Preview Example

State of Illinois

Department of Employment Security

Refusal of Work Questionnaire - Employer

Claimant Information:









Last Name:


First Name:







Employer Name:




Employer Account #:


Under Section 603 of the Illinois Unemployment Insurance Act, an individual shall be ineligible for benefits if he/she failed, without good cause, either to apply for available, suitable work when so directed by the employment office or the Director, or to accept suitable work when offered to him/her by the employment office or an employing unit, or return to his/her customary self-employment (if any) when so directed by the employment office or the Director. Please provide details about the refusal. The information you provide will be used for the purpose of determining the claimant’s eligibility for benefits.

Please complete, sign and return this questionnaire to the Illinois Department of Employment Security Office as instructed. If you need additional space, please use the other side of this document, if appropriate, or attach a separate sheet of paper.

This state agency is requesting information that is necessary to accomplish the statutory purpose as outlined in 820 ILCS 405/100-3200. Disclosure of this information is voluntary. However, failure to disclose this information may result in the erroneous payment of Unemployment Insurance benefits which may affect the amount of your liability for contributions or payments in lieu of contributions.

Thank you for your cooperation in this matter.

Section A: Refusal of Work Information

Did the claimant receive an offer of work or a referral from the Employment Services or an employing unit?










If No, then no further information is required. Skip to Section B.

What is the name and address of the employing unit making the offer?

Employer Name/Doing Business As:

Address 1:




Address 2: (Apt, Floor, Suite, etc.)










Zip Code:




What is the name and title of the person who made the offer?



How was the offer of work conveyed? (Check all that apply)

In Person Telephone Letter E-mail What was the date of the offer of work or referral to a job?

What was the start date of the job?





What were the scheduled hours and days of work?

Other (Please Explain)

/ /

Scheduled hours and days of work






Starting rate of pay



per (Hr/Day/Week/Etc.)

Work Location









Job Title:





Job Duties:


What was the reason for the refusal of work/referral?

Provide details of past employment including dates of employment, job duties, training and experience in this type of work.

Section B: Signature















Name (Printed)















Page 1 of 1



Rev. (09/2011)

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This PDF form will involve some specific details; in order to ensure correctness, don't hesitate to take note of the tips hereunder:

1. You will need to fill out the Form Adj016Fe properly, thus be mindful while filling in the parts including these particular fields:

Form Adj016Fe writing process described (portion 1)

2. Right after performing this section, head on to the next stage and complete all required details in these blank fields - Name, Title How was the offer of work, In Person Telephone Letter Email, What was the date of the offer of, What was the start date of the job, What were the scheduled hours and, Scheduled hours and days of work, Starting rate of pay per, Work Location, Job Title Job Duties, What was the reason for the, Section B Signature, Signature Title Date, Name Printed Telephone Ext, and ADJFE Page of NEW Rev.

Work Location, ADJFE Page  of  NEW Rev, and In Person Telephone Letter Email of Form Adj016Fe

In terms of Work Location and ADJFE Page of NEW Rev, be certain that you take another look in this section. Those two are surely the most important ones in the document.

Step 3: Prior to finalizing this document, it's a good idea to ensure that blank fields have been filled in the correct way. As soon as you believe it is all fine, click “Done." Sign up with us today and easily use Form Adj016Fe, ready for download. All adjustments you make are saved , helping you to edit the form at a later time as needed. When you use FormsPal, you'll be able to fill out documents without having to get worried about database breaches or entries being distributed. Our protected system makes sure that your private information is maintained safely.