NONMONETARY DETERMINATIONS QUALITY DATA COLLECTION INSTRUMENT

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

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

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.