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12/21/2024
Reporting of Interview No Show or Refusal of Work Offered
SFN 61977
Employer Information
*Employer Business Name
*Employer Address
*City,
State
Zip
AL
AK
AZ
AR
CA
CO
CT
DE
DC
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
Person Reporting Information
*First
MI
Last Name
*Phone Number
(222-333-4444)
Applicant Information
*First
MI
Last Name
*Phone Number
(222-333-4444)
Email
(email@host.com)
*Status
No Show for Interview
Refused Offer of Work
Unable to Contact for Interview, Offer Work, or Recall to Work
No Show for Interview Information
*Date of Interview
*Date Applicant Notified of the Interview
*How was the Applicant notified?
Text Message
Letter
Verbal-In Person
Verbal-Via Telephone
Email
*Did the Applicant confirm their attendance for the interview?
Yes
No
*Did the Applicant contact you prior to the interview date to reschedule?
Yes
No
Work Refusal Information
*Date Offer of Work was Made
*Position Offered
*Summary of Position Duties
*Starting Date of the Work
*Hourly Pay Rate Offered
$
*Reason the Applicant provided for refusing the work offered
Unable to Contact Information
*Reason for contact
Unable to Contact for Interview
Unable to Contact for Offer Work
Unable to Contact for Work Recall
*Date Contact Attempted
Second Date Contact Attempted
*Total Number of Attempts You Made to Contact the Individual
*Methods Used to Contact the Individual
Telephone
Text
Email
In Person
Other
Contact Phone 1
(222-333-4444)
Contact Phone 2
(222-333-4444)
Contact Phone 3
(222-333-4444)
Contact Email 1
(email@host.com)
Contact Email 2
(email@host.com)
Contact Email 3
(email@host.com)
*Required