Decision review worksheet

Print this page or save it locally. Do not submit it to
uiappeals.com/.

Document identity

• Document title: ______________________________________________
• Agency/tribunal: _____________________________________________
• Claimant or reference number (keep private):
  _____________________
• Date issued/mailed: __________________________________________
• Date actually received: _______________________________________
• Appeal date printed on notice:
  _________________________________
• Permitted filing methods: _____________________________________
• Affected weeks: ______________________________________________
• Amount or penalty: ___________________________________________

What did the agency decide?

Check every applicable item:

• Monetary eligibility
• Misconduct discharge
• Voluntary quit
• Able and available
• Suitable-work refusal
• Earnings/reporting
• Overpayment
• Fraud or willful
  misrepresentation
• Identity/account issue
• Timeliness
• Employer appeal
• Other:
  _________________________________________________

Exact reason stated

Separate notices

List every other determination or decision involving the same
weeks:

Proof preserved

• Full notice
• Envelope/electronic service
  record
• Portal screenshot
• Appeal copy
• Confirmation/fax/mail
  receipt
• Agency communications

Immediate unanswered
questions

Jurisdiction field

Add the state, agency, tribunal, official terminology, burden,
evidence rule, appeal deadline shown on the notice, and current source
used. This worksheet does not calculate or verify a deadline.

Local-use note: Complete or save this worksheet on your own
device or on paper. It is not submitted through uiappeals.com/.