Helpside Unemployment Case Questionnaire

Email *

What is the claimant's name and last four of their social security number if available? *

What was the last day the claimant performed work? *

Did they become separated on the same day? *

If no, what was the date *

Separation Reason

Please choose the separation reason below.

Separation Reason *

Temporary Layoff
Laid off/Lack of work
Fired/Discharged
Voluntary Quit
Vacation/Holiday Shutdown
Education Institution Employee Between Semesters or Terms, Likely to Return
Education Institution Employee Between Semesters or Terms, Not Likely to Return
Still Employed, Full Time
Still Employed, Part Time
Still Employed, Hours Reduced
On Call/Temporary Status
Leave of Absence
Retirement
Disaster Related
Labor Dispute
Asked to Resign
Suspension
Professional Athlete In Between Sports
Refuse to provide
Other

Fired/Discharged

Please choose one.

If they were Fired/Discharged, what was the reason? *

Not Qualified/Inadequate Performance
Absenteeism/Tardiness
Failed to follow instructions/Policy/Contract
Drugs
Dishonesty
Failed Employment Requirements
Alcohol
Theft
Felony/Misdemeanor/Violation of law/Criminal acts/Illegal
Property Damage
Physical/Verbal Altercation
Other

Temporary Layoff

Do you know the date the claimant is returning to work? *

If yes, what is the date? *

Laid off/ Lack of work

Additional Details?

Voluntary Quit

Voluntary Quit Reason *

No reason given
Seek or Accept other employment
Health Reasons
Job Dissatisfaction
Personal Reasons
Failure to report to work/abandonment
Retirement
Working Conditions
Other

On Call/Temporary Status

Is claimant working all available hours? *

If no, why?

Not Qualified/Inadequate Performance

Was the inadequate performance due to carelessness or negligence?

Was the claimant able to meet the employer's performance expectations in the past?

Did anything change about the job?

If yes, what?

Date of final incident? *

Describe in detail the final incident that caused the discharge. *

Did the claimant violate company policy?

Absenteeism/Tardiness

Date of final incident? *

Describe in detail the final incident that caused the discharge *

What was the reason the claimant gave for the final absence/tardiness? *

Did the claimant violate company policy? *

Failed To Follow Instructions/Policy/Contract

Date of final incident? *

Describe in detail the final incident that caused the discharge *

Did they violate company policy? *

Policy

If claimant had a policy violation, the state would like you to attach the policy at the end of the questionnaire.

Was the claimant aware of the policy or expected behavior? *

How was the claimant informed of the policy or the expected behavior? *

Written
Verbal
Both

Drugs/Alcohol

Date of final incident? *

Describe in detail the final incident that caused the discharge *

Was the claimant asked to submit to a test? *

If yes, was a test performed? *

If no, why not? *

Why was the test requested? *

New hire
Post Accident
Behavior
Random
Employee Assistance

Did the claimant violate company policy? *

Dishonesty

Date of final incident? *

Describe in detail the final incident that caused the discharge. *

How did the act adversely affect the employer? *

Did the claimant violate company policy? *

Failed employment requirements

Date of final incident? *

Describe in detail the final incident that caused the discharge *

Did the claimant violate company policy? *

Theft

Date of final incident? *

Describe in detail the final incident that caused the discharge. *

What did the claimant steal? *

How did the act adversely affect the employer? *

Was there a value attached to the act? *

Yes
No
Unknown

Did the claimant admit to the theft? *

If no, how does the employer know about the theft? *

Were there witnesses to the theft? *

Yes
No
Unknown

Did the claimant violate company policy? *

Felony/Misdemeanor, Violation of Law, Criminal, Illegal Acts

Describe in detail the final incident that caused the discharge. *

What act did the claimant commit that violated the law? *

How did the act adversely affect the employer? *

Did the claimant violate company policy? *

Property Damage

Date of final incident? *

Describe in detail the final incident that caused the discharge. *

Who reported the damage? *

Did the claimant admit to causing the damage? *

If no, how did the employer know the claimant was responsible for the damage? *

Were there witnesses to the property damage? *

Yes
No
Unknown

Did the claimant violate company policy? *

Physical/Verbal Altercation

Date of final incident? *

Describe in detail the final incident that caused the discharge. *

Did the altercation take place on company property? *

Did the altercation take place on company time? *

Did the claimant start the altercation? *

Yes
No
Unknown

Could the claimant have avoided the altercation? *

Yes
No
Unknown

Were there witnesses to the altercation? *

Yes
No
Unknown

If yes, provide witness's first and last name and job title

Can you attach a witness statement down below? *

Did the claimant violate company policy? *

Not Listed

Date of final incident? *

Describe in detail the final incident that caused the discharge. *

Did the claimant violate company policy? *

Voluntary quit questions

Was continuing work available? *

Were there changes in the claimant's hiring agreement that contributed to the claimant quitting this job? *

If yes, what were the changes?

Did the claimant take actions to avoid quitting? *

Did the claimant give notice? *

Yes
No
Unknown

Vacation/Holiday Shutdown

Is the claimant returning to work? *

If yes, do you know the date the claimant is returning to work?

If yes, what is the date of return?

Education Institution Employee Between Semesters or Terms, Likely to Return

Reason for break *

Customary Break/Holiday
Between academic years

First day of break for claimant? *

Last day of break for claimant? *

What position will the claimant be returning to? *

Still Employed, Part Time

Is the claimant working all available hours?

Yes
No
Unknown

If no, why is the claimant not working all available hours?

Still Employed, Hours Reduced

Who reduced the claimant's hours? *

Claimant
Employer

Is the claimant working all available hours? *

Yes
No
Unknown

If no, why is the claimant not working all available hours?

On Call/Temporary Status

Is the claimant working all available hours? *

Yes
No
Unknown

If no, why is the claimant not working all available hours?

Leave of Absence

Why is the claimant on a leave of absence? *

When the leave began, was a return to work date agreed upon? *

Yes
No
Unknown

If yes, what is the projected return to work date?

Retirement

Was the retirement mandatory? *

Yes
No
Unknown

If yes, why was the claimant required to retire?

If no, why did the claimant retire?

Was continuing work available? *

Were there changes in the claimant's hiring agreement that contributed to the claimant quitting this job?

Disaster Related

Why is the claimant not working? *

Is work available? *

Education Institution Employee Between Semesters or Terms, Not Likely to Return

Why is the claimant not likely to return? *

Laid Off/Lack of work
Fired/Discharged
Asked to Resign
Voluntary Quit
Retirement
Labor Dispute
Disaster Related
Not Listed Above
Refuse to provide

Asked to Resign or Suspension

Multiple Choice *

Not Qualified/Inadequate Performance
Absenteeism/Tardiness
Failed to follow instructions/policy/contract
Drugs
Dishonesty
Failed employee requirements
Alcohol
Theft
Felony/Misdemeanor/Violation of Law/Illegal Acts/Criminal
Property Damage
Physical/Verbal Altercation
Not listed above

Labor Dispute

Is the claimant not working due to a strike or a lockout? *

Strike
Lockout

available I to

When did the labor dispute begin? *

Has the labor dispute ended? *

If yes, when did it end?

Has a permanent replacement worker been hired? *

Yes
No
Unknown

Is the employee a member of the striking union? *

If no, explain fully why the employee is now unemployed?

Will settlement of the labor dispute affect the employee's wages, hours, or working conditions? *

If yes, describe how?

Professional Athlete In Between Sports

First day of contract *

Last day of contract *

Has a new contract or job offer been made? *

Yes
No
Unknown

If no, why was a new contract or job offer not made? *

If yes, how was the new offer of work conveyed?

Written
Verbal
Both

If yes, who offered the claimant reasonable assurance for continued employment?

If yes, did the individual have the authority to make the offer?

By selecting REFUSE TO PROVIDE, I acknowledge that I have not provided the requested information either because it is not available, or I am unwilling or cannot present the information requested. I understand and agree that the state will proceed in making a determination based on the information on file. Failure to provide the information requested may have an adverse effect on the employer account.

I agree

Additional Details

Did or will the claimant receive any compensation on or after the last day of work (excluding wages for hours worked)? Ex: separation pay, severance, PTO pay, etc. *

Yes
No
Unknown

If yes, what kind of pay, how much, and when will it be administered to the claimant?

Who discharged the claimant and what was their job title? *

Were there prior instances? *

If yes, please list the dates, incident details, and attach any supporting documentation down below.

Any additional information?

Do you have any documentation you can upload or send to voe@helpside.com? Examples: Warnings, Corrective Action Forms, Emails, Policy/Handbook, Photos, Texts, Any Relevant Documentation *

Upload
Email

File Upload

Drag & Drop Files, Choose Files to Upload

If you chose email above, please provide the documentation by sending it to voe@helpside.com with the Name of the Claimant in the subject line followed by "UI Claim Documentation" This is the end, thank you!! 🙂