Fact-Finding Questionnaires (adjudication)

The Department has developed fact finding questionnaires for claimants and employers to expedite the telephone interview with the Central Adjudication Unit. Questionnaires are broken into several categories based on topic. Your adjudication appointment letter may indicate the circumstances that apply to the issue being addressed.

Please complete and return the questionnaire that best fits your situation. You may email the questionnaire as an attachment to DLT.CAUinterview@dlt.ri.gov or fax to (401) 462-8318 within 48 hours before the date of your telephone interview or as soon as possible.

If you do not wish to provide a statement, please complete the Decline to Provide a Statement Form. Please note if you decline to provide a statement, the Department will render a decision based only upon the facts present at the time the determination is made and the department will not contact you for a statement.

For Claimants

Decline to Provide a Statement

Decline to Provide a Statement PDF file, less than 1

Availability Questionnaires

Childcare PDF file, less than 1

Out of Area PDF file, less than 1

Family Responsibility PDF file, less than 1

Personal Vacation PDF file, less than 1

Incarceration PDF file, less than 1

Transportation PDF file, less than 1

Leave of Absence PDF file, less than 1

Under Medical Care PDF file, less than 1

Minor Under 16 PDF file, less than 1

Refusal of Referral from DLT Counselor or EmployRI PDF file, less than 1

Discharge Questionnaires

Suspended (Unpaid) PDF file, less than 1

Failure to Report Absence PDF file, less than 1

Absenteeism & Tardiness PDF file, less than 1

Altercation PDF file, less than 1

Away from Work Station PDF file, less than 1

Damaging Company Property PDF file, less than 1

Failed Drug Test PDF file, less than 1

Falsify Company Documents PDF file, less than 1

Involuntary Retirement PDF file, less than 1

Job Performance PDF file, less than 1

License: Suspension or Loss PDF file, less than 1

Other Discharge PDF file, less than 1

Refusing Assigned Duties PDF file, less than 1

Refusing Overtime PDF file, less than 1

Sleeping on the Job PDF file, less than 1

Stealing PDF file, less than 1

Unauthorized Use of Company Property PDF file, less than 1

Under the Influence of Intoxicants PDF file, less than 1

Pension

Private or Government PDF file, less than 1

Military PDF file, less than 1

Refusal of Work

Refusal of Work PDF file, less than 1

Voluntary Quits

Accept Other Work PDF file, less than 1

Attend School or Training PDF file, less than 1

Care for Ill or Disabled Family Member PDF file, less than 1

Change in Contract or Terms of Hire PDF file, less than 1

Child Care Issues PDF file, less than 1

Company Relocation PDF file, less than 1

Distance to Work PDF file, less than 1

Domestic Violence PDF file, less than 1

Got Married PDF file, less than 1

Health or Medical Reasons PDF file, less than 1

Incarceration Voluntary Quit PDF file, less than 1

Reduced Work Hours PDF file, less than 1

Relocate Personal PDF file, less than 1

Relocate with Spouse PDF file, less than 1

Retire PDF file, less than 1

Sexual Harassment PDF file, less than 1

Sold Business as Owner PDF file, less than 1

Transportation Issues PDF file, less than 1

For Employers

Decline to Provide a Statement

Decline to Provide a Statement (Employer) PDF file, less than 1

Discharged Questionnaries

Suspended Unpaid (Employer) PDF file, less than 1

Stealing (Employer) PDF file, less than 1

Unauthorized Use of Company Property (Employer) PDF file, less than 1

Under the Influence of Intoxicants (Employer) PDF file, less than 1

Absenteeism & Tardiness (Employer) PDF file, less than 1

Failure to Report Absence (Employer) PDF file, less than 1

Altercation (Employer) PDF file, less than 1

Away from Work Station (Employer) PDF file, less than 1

Damaging Company Property (Employer) PDF file, less than 1

Failed Drug Test (Employer) PDF file, less than 1

Falsify Company Documents (Employer) PDF file, less than 1

Involuntary Retirement (Employer) PDF file, less than 1

Job Performance (Employer) PDF file, less than 1

License: Suspension or Loss (Employer) PDF file, less than 1

Other Discharge (Employer) PDF file, less than 1

Refusing Overtime (Employer) PDF file, less than 1

Refusing Assigned Duties (Employer) PDF file, less than 1

Sleeping on the Job (Employer) PDF file, less than 1

Pension

Private or Government (Employer) PDF file, less than 1

Military (Employer) PDF file, less than 1

Refusal of Work

Refusal of Work (Employer) PDF file, less than 1

School Employees

Summer Break or Between Semesters (Employer) PDF file, less than 1

School Vacation Period (Employer) PDF file, less than 1

Voluntary Quits

Accept Other Work (Employer) PDF file, less than 1

Attend School or Training (Employer) PDF file, less than 1

Care for Ill or Disabled Family Member (Employer) PDF file, less than 1

Change in Contract or Terms of Hire (Employer) PDF file, less than 1

Child Care Issues (Employer) PDF file, less than 1

Company Relocation (Employer) PDF file, less than 1

Distance to Work (Employer) PDF file, less than 1

Domestic Violence (Employer) PDF file, less than 1

Got Married (Employer) PDF file, less than 1

Health or Medical Reasons (Employer) PDF file, less than 1

Incarceration Voluntary Quit (Employer) PDF file, less than 1

Not Paid Correct Amount (Employer) PDF file, less than 1

Other Voluntary Quit (Employer) PDF file, less than 1

Relocate Personal (Employer) PDF file, less than 1

Relocate with Spouse (Employer) PDF file, less than 1

Reduced Work Hours (Employer) PDF file, less than 1

Involuntary Retirement (Employer) PDF file, less than 1

Sexual Harassment (Employer) PDF file, less than 1

Sold Business as Owner (Employer) PDF file, less than 1

Transportation Issues (Employer) PDF file, less than 1