NONMONETARY DETERMINATIONS QUALITY DATA COLLECTION INSTRUMENT

1. IDENTIFICATION #: 00000 (5-digit sample sequence) SKELETON FIELD PAGE V - 1
2. ISSUE CODE: (2-digit code) SKELETON FIELD PAGE V - 1
3. CASE MATERIAL FOUND? (Y/N) (If "N", remaining elements are left blank) PAGE V - 1
4. CORRECT ISSUE CODE? (Y/N) (If "Y", then item 5 is blank) PAGE V - 2
5. IF ITEM 4 IS "N", ENTER THE CORRECT CODE FROM BELOW. (If no issue existed, enter "00"; if a nonmonetary redetermination, enter "01") PAGE V - 2

SEPARATION

NON-SEPARATIONS

MULTICLAIMANT

 
10 Quit

20 Discharge (MC)

29 Other

 30 Able/Available

40 Work Search

50 Disq/ded. Income

60 Suitable Work

70 JS Registration

71 Fail to App/Accept

Referral

72 Training

73 Profiling

 80 School Employee

81 Alien

82 Athlete

83 Unemployment Status

84 Seasonality

85 Removal of DQ

89 Reporting- Requirements /Misrepresentation/Other

 90 Labor Dispute

99 Other

  
6. INTRASTATE CLAIM? (Y/N) PAGE V - 6
7. PROGRAM TYPE: UI UCFE UCX PAGE V - 6
8. NONMONETARY DETERMINATION OUTCOME: ALLOWED DENIED PAGE V - 7
9. OUTCOME REPORTED CORRECTLY? (Y/N) PAGE V - 7
10. SESA USE ONLY: (4 characters) PAGE V - 8
11. WEEK CLAIMED? (Y/N) SKELETON FIELD PAGE V - 8
12. W/E DATE OF FIRST WEEK AFFECTED BY DETERMINATION: (mmddyyyy) SKELETON FIELD PAGE V - 8
13. CORRECT WEEK ENDING DATE? (Y/N) PAGE V - 9
14. CORRECTED WEEK ENDING DATE (blank if item 13 is "Y"): (mmddyyyy) PAGE V - 9
15. ISSUE DETECTION DATE: (mmddyyyy) PAGE V - 10
16. CORRECT ISSUE DETECTION DATE? (Y/N) PAGE V - 10
17. CORRECTED ISSUE DETECTION DATE (blank if item 16 is "Y"): (mmddyyyy) PAGE V - 11
18. CLAIMANT INFORMATION: Adequate=10, Inadequate=5, Not Obtained=0, NA(X)=10 V-13  
19. EMPLOYER INFORMATION: Adequate=10, Inadequate=5, Not Obtained=0, NA(X)=10 V-16  
20. INFO./FACTS FROM OTHERS: .Adequate=10, Inadequate=5, Not Obtained=0, NA(X)=10 V-17  
21. REBUTTAL OPPORTUNITY PROVIDED: Offered/10, Not offered/0, NA(X)/10 V-18  
22. LAW/POLICY: Meets/50, Questionable=30, Does not meet (X)=0 V-20  
23. WRITTEN DET.: Adequate=10, Inadequate=5, Wrong (X)=0 (If "X" then #22 cannot be "M") V-21  
24. APPEAL INFORMATION PROVIDED: Sufficient/Not Applicable (S) Insufficient (I) PAGE V - 24
25. DATE OF DETERMINATION: (mmddyyyy) SKELETON FIELD PAGE V - 25
26. DETERMINATION FULLY IMPLEMENTED? (Y/N) PAGE V - 26
27. DATE DETERMINATION FULLY IMPLEMENTED: (mmddyyyy) PAGE V - 27

 

COMMENTS **



CLAIMANT INFORMATION

ADEQUATE / 10

INADEQUATE / 5

NOT OBTAINED / 0

NOT APPLICABLE / 10

COMMENTS:









EMPLOYER INFORMATION

ADEQUATE / 10

INADEQUATE / 5

NOT OBTAINED / 0

NOT APPLICABLE / 10

COMMENTS:





FACTS FROM OTHERS

ADEQUATE / 10

INADEQUATE / 5

NOT OBTAINED / 0

NOT APPLICABLE / 10

COMMENTS:









REBUTTAL OPPORTUNITY

OBTAINED / 10

NOT OBTAINED / 0

NOT APPLICABLE / 10

COMMENTS:

 

 



LAW & POLICY

MEETS / 50

QUESTIONABLE / 30

DOES NOT MEET / 0

COMMENTS:









WRITTEN DETERMINATION

ADEQUATE / 10

INADEQUATE / 5

WRONG / 0  

COMMENTS:       

                                                                                                                                                                                                        TOTAL:

COMMENTS ON OTHER ELEMENTS:

** ENTERING SCORES ON THE COMMENT PAGE IS OPTIONAL.