Form 60-0154 - Notice Of Separation Or Refusal Of Work Under Conditions That May Disqualify
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1NOTICE OF SEPARATION OR REFUSAL OF WORK UNDER CONDITIONS THAT MAY DISQUALIFY 60-0154 (09-2016)
Instructions On Reverse
WORKER’S NAME
SOCIAL SECURITY NUMBER
(Date) Separation or refusal to work
Day
Year
Month
EMPLOYMENT WAS TERMINATED FOR THE REASON CHECKED
Discharged for
Refused
Voluntary
Left
The Protest Box and Complete Separation or Refusal of Work Date
Misconduct in
Quit
Suitable Work
to take
MUST BE INDICATED on all responses. . . . . . . . . . . .
Connection With
or Recall
other
Work
To Work
employment
IOWA ACCOUNT NUMBER
If Applicable, Location Code
INTERVIEW INFORMATION
If a fact-finding interview is necessary, you will be scheduled for an interview by telephone unless it is
impractical to do so.
EMPLOYER
NAME OF PERSON who will participate in a fact-finding interview for this employer.
PRINT LEGIBLY
Name_____________________________________________________________________________
Title______________________________________________________________________________
Telephone number for fact-finding interview
EMPLOYER ADDRESS
(Street, City, State and Zip Code)
__________________________________________________________________________________
(Area Code)
Phone Number
SUPPORTING DOCUMENTS may be submitted with this form for consideration at the telephone
fact-finding. The separation information you provide must be Certified Correct By Signing and
Completing the Signature Box.
CERTIFIED CORRECT BY (Signature Required) __________________________________
TITLE _____________________________________
Date ____________
FOR DEPARTMENT USE ONLY:
O.C. ________________________L.O.# ____________________________
NOTICE OF SEPARATION OR REFUSAL OF WORK UNDER CONDITIONS THAT MAY DISQUALIFY 60-0154 (09-2016)
Instructions On Reverse
WORKER’S NAME
SOCIAL SECURITY NUMBER
(Date) Separation or refusal to work
Day
Year
Month
EMPLOYMENT WAS TERMINATED FOR THE REASON CHECKED
Discharged for
Voluntary
Refused
Left
The Protest Box and Complete Separation or Refusal of Work Date
Quit
Misconduct in
Suitable Work
to take
MUST BE INDICATED on all responses. . . . . . . . . . . .
Connection With
or Recall
other
Work
To Work
employment
IOWA ACCOUNT NUMBER
If Applicable, Location Code
INTERVIEW INFORMATION
If a fact-finding interview is necessary, you will be scheduled for an interview by telephone unless it is
impractical to do so.
EMPLOYER
NAME OF PERSON who will participate in a fact-finding interview for this employer.
PRINT LEGIBLY
Name_____________________________________________________________________________
Title______________________________________________________________________________
Telephone number for fact-finding interview
EMPLOYER ADDRESS
(Street, City, State and Zip Code)
__________________________________________________________________________________
(Area Code)
Phone Number
SUPPORTING DOCUMENTS may be submitted with this form for consideration at the telephone
fact-finding. The separation information you provide must be Certified Correct By Signing and
Completing the Signature Box.
CERTIFIED CORRECT BY (Signature Required) __________________________________
TITLE _____________________________________
Date ____________
FOR DEPARTMENT USE ONLY:
O.C. ________________________L.O.# ____________________________
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