Form Oes-622a - Eligibility Review Questionnaire

Oklahoma Employment Security Commission

Eligibility Review Questionnaire

Social Security Number:

Claimant Name:

Completion Instructions

You were required to make two work search efforts each week you claim unemployment benefits. This form is designed to record the results of those efforts for the two weeks

prior to your scheduled interview. Please complete all fields and answer all questions. If you found the contact in a publication and the name of the employer was not listed,

provide the name and date of the publication. If you sent an application by email or completed an application online, include the email or web address. Work search efforts must be

made during the week in which benefits are claimed. Failure to complete work search efforts will result in a disqualification of benefits. Week dates must run Sunday through

Saturday. Example: Your interview is scheduled for November 16, 2015. The form should be completed for the weeks of November 1-7 (first week) and November 8-14 (second

week).

FIRST Week Beginning ______________ through Week Ending _______________

Employer

Name of

Method of

Date

Employer Name and Address

Type of Work

Results

Telephone

Contact

Contact

SECOND Week Beginning ______________ through Week Ending ______________

Employer

Name of

Method of

Date

Employer Name and Address

Type of Work

Results

Contact

Telephone

Contact

What can we do to help you get back to work? __________________________________________________________________________________________________

Do you require any assistance in updating your resume or help accessing Oklahoma Job Match? __________________________________________________________

I understand that my required number of work search efforts has been increased from two (2) to four (4) per week effective today. I understand that:

•

Work search contacts can only be repeated after four (4) weeks;

•

Contacts must be for work I am willing and qualified to do;

•

Contacts must be made with an individual who has reasonable knowledge of job openings and if written applications are accepted, filed with the appropriate

personnel;

•

Multiple contacts with one employer are permissible provided they are not for the same job.

•

I must stop filing when I return to work and notify the Commission of my new job.

Claimant signature: _____________________________________________

Date:______________________________________

Auxiliary aids and services are available upon request to individuals with disabilities.

OES-622A

(Rev 1-26-16)