VQ - RSW - A & A

Questionnaire FOR COVID-19

COVID-19 QUESTIONNAIRE
Voluntary Quit -– Able & Available - Refusal Suitable Work
In order to determine the claimant's eligibility for UC, it is requested that you
answer the following questions:

Claimant Name Taylor Tretick Social Security 223-79-5940

Last Employer’s Name__Children’s Behavioral Health

Employer’s Address: 1001 Broad St, Suite 210 Johnstown, PA 15906

Employer’s Telephone No. 814-262-0768 ext 22 Employer’s FAX No. 814-262-
0795

What was the: first date worked? 08/07/2019

last date worked? 06/05/2020
The following sections are specific to whether there was a voluntary quit from
employment, and/or a potential able and available issue exists for suitable work, OR
whether an offer to return to suitable work was refused.

Please complete the section for Voluntary Quit if at the time of a return to work
offer, a worker-employer relationship existed. For example, a future potential return
to work date was understood, even though not presented in writing. In addition,
please complete the section for Able and Available if a potential COVID-19 reason
is preventing a possible return to work. Please continue on this page and
following.

Please complete the section for Refusal of Suitable Work if at the time of a return
to work offer, a worker-employer relationship did not exist and there was a
permanent separation (lack of work, discharge, or the claimant quit). Please go to
the section titled: Refusal of Suitable Word – COVID-19 to complete
questions.

VOLUNTARY QUIT for COVID-19

1. Is this separation a voluntary quit or a leave of absence?
Voluntary Quit ✘ Leave of Absence
Note: For the purposes of UC, a leave of absence is treated like a voluntary quit.
If a leave of absence:
Leave of absence begin date:
Leave of absence end date:
If the end date is unknown, check this box
2. What was the reason for leaving employment?

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Please explain: not enough hours due to covid

3. What was the date of hire? 08/07/2019
What was the last actual date worked? 06/05/2020
4. In what county is the workplace? Cambria
5. On what date was the recall to work made? Around 03/30/2020
6. What was the report back to work date? 03/31/2020

7. Was teleworking offered? Yes ✘ No

Please explain: schools were closed 03/16/2020-03/27/2020 and telework
began on 03/31/2020

8. On the report back to work date, was the county of the employment located
under a business closure order? Yes ✘ No
If no, because the employment is located in a county designated GREEN:
Why was there no return to work?

Was there an attempt to resolve the issue prior to the quit? Yes No
Please explain:

If yes:
What is the name and title of the person with whom an attempt to resolve
the issue was made?
When did the attempt to resolve the issue occur?
(Please provide a specific date and/or time.)
If yes, because the employment is located in a county designated RED:
Is the employment considered to be a life sustaining business?
Yes ✘ No
(If no, additional questions are not required)
If yes:
Was the business exempt from the Governor’s closure order?
Yes No ✘
If yes, on what date did the exemption become effective?

Was the exemption in effect at the point of the recall to work?

Yes No
If no, was there an exemption in place when a return to work date was
given? Yes, schools were ordered closed so the company set up
telework

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Why was there a refusal to return to work?

Was there an attempt to resolve the issue before quitting? Yes ✘ No

If yes, please explain: company did not have enough hours to meet
my quality of life

What is the name and title of the person with whom an attempt to
resolve the issue was made? Case Manager Carrie Savage
When did the attempt to resolve the issue occur? On-going basis from
03/31/2020
(Please provide a specific date and/or time.)
Was there information given that measures were taken to protect
employees and customers against further spread of COVID -19?
Yes ✘ No
If yes, how was notification given/received? email
If yes, because the employment is located in a county designated YELLOW:
Why was there a refusal to return to work?

If an exemption to the governor’s closure order was granted, was this made
clear to all interested parties? Yes No
Please explain:

Was there an attempt to resolve the issue prior to the quit? Yes No
Please explain:

If yes:
What is the name and title of the person with whom an attempt to resolve
the issue was made?
When did the attempt to resolve the issue occur?
(Please provide a specific date and/or time.)
Was there a discussion regarding any special needed/requested
accommodations? Yes No
If yes, please explain:

What measures were taken, and advised, would be in place to prevent the
spread of COVID-19?
Was the position, pay and location of the recall to work the same prior to the
COVID-19 pandemic and when the recall to work was offered?

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Yes No
If no, please explain:

9. Do you want to provide any additional information that you feel may have a
bearing on the claimant’s eligibility for unemployment compensation? (If
information exceeds provided space, please include additional sheets as attachment)

(To complete the form regarding a potential Able and Availability issue,
please continue)

ABLE AND AVAILABLE for COVID-19

1. Are you able to work from home? Yes ✘ No

Please explain:

2. Are you unable to return to work due to the employer being closed due to the
COVID-19 pandemic? Yes ✘ No
If yes, please explain: from 03/16/2020-03/27/2020 because schools were
closed. Began reduced hours by teleworking on 03/31/2020.

3. Are you in self-quarantine as a result of COVID-19? Yes No ✘

If yes, please explain:

4. Have you been diagnosed with COVID-19, or are you experiencing symptoms and
seeking medical diagnosis? Yes No ✘
5. Has a member of your household been diagnosed with COVID-19?
Yes No ✘
If yes, please explain:

6. Are you caring for a household or family member who has been diagnosed with
COVID-19? Yes No ✘
If yes, please explain:

7. Are you unable to reach your place of employment because of a quarantine

imposed as a direct result of COVID-19? Yes No ✘

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Please explain:

8. Are you unable to reach your place of employment because you were advised by
a healthcare provider to self-quarantine as a direct result of COVID-19?
Yes No ✘
Please explain:

9. Are you unable to return to work due to health issues? Yes No ✘

If yes, please explain.

10. Are you unable to return to work due to child care (if needed)? Yes No ✘
If yes, please explain.

11. Are you unable to return to work because the child care facility is/was closed
due to COVID -19? Yes No ✘

(To complete the form regarding a potential Refusal of Suitable Work for
both Temp Agencies and regular employment,
please move to the following section)

REFUSAL OF SUITABLE WORK for COVID-19

1. Was there a specific job offer made that was refused? Yes No
If yes, was it a new job offer or an offer to return to work?
New Job Offer Return to Work
If this was an offer to return to work, was the work offered the same job
held prior to the COVID-19 emergency? Yes No

If no, please explain:

2. What reason was given for the refusal of the job offer or recall to work?

3. Was work previously performed with this employer? Yes No

If yes, when?
Was there a separation due to the COVID-19 emergency? Yes No
If no, please describe the nature of the separation from employment.

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4. What date was the job offer/recall to work made?

Name and title of the individual who made the job offer/recall to work.

How was the job offer or recall to work made? In Writing Verbally
Was the job offer/recall to work made through a temporary staffing agency?
Yes No
If yes, provide the following:
Temporary Staffing Agency’s Name:
Address:
Phone Number:
Provide the following information regarding the assignment at the client
employer (i.e., where the work would be performed).
Client Employer’s Name:
Client Employer’s Address:
Client Employer’s Phone Number:
If no, provide the following:
Employer’s Name:
Employer’s Address:
Employer’s Phone Number:
5. What were the duties of the job that was offered?
What was the offered rate of pay?
What work hours were offered?
Was the offered job Full-time Part-time
If part-time, how many hours per week was the offered work?
Was the offered job: Temporary Permanent
If temporary, on what date was the job scheduled to end?
What was the work location of the job that was offered?
On what date was the job to begin?
6. If this was an offer to return to work, was the work offered the same job held
prior to the COVID-19 emergency? Yes No N/A
If yes, were there any modifications to the job duties or working hours at the
time of recall? Yes No
If yes:
Please describe the modifications.

What was the rate of pay prior to the COVID-19 emergency?

per .

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What was the offered rate of pay at the time of recall? per .
If no, please explain.

7. Please describe any steps that were taken to provide for safety at work
regarding the COVID-19 emergency.

8. Please provide any additional information that may affect eligibility for
unemployment compensation.

1. I acknowledge that false statements in this document are punishable pursuant to 18 Pa.
C.S. §4904, relating to unsworn falsification to authorities.
2. All information provided is true, correct and complete to the best of my knowledge and
belief.
3. FOR EMPLOYEES: I acknowledge that a person who makes a false statement or
representation knowing it to be false, or knowingly fails to disclose a material fact to
obtain or increase any UC benefits commits a criminal offense under Section 801(a) of
the UC Law, 43 P.S. § 871(a), and may be subject to a fine, imprisonment and
restitution.
4. FOR EMPLOYERS: I acknowledge that an employer or any officer or agent of such
employer who makes a false statement or representation knowing it to be false or who
fails to disclose a material fact to prevent or reduce the payment of UC benefits to any
employee commits a criminal offense under Section 802(a)(1) of the UC Law, 43 P.S.
872(a)(1).

Name: Taylor Tretick Date: 11/20/2020

Title (if employer): Telephone Number:
Information provided by telephone to UC representative: On:
(Initials)