Labor Dispute Questionnaire (Employer)

							Employer                                      Illinois Department of Employment Security
                                              33 South State Street * Chicago, Illinois 60603

                                               LABOR DISPUTE QUESTIONNAIRE


1.   Employer:        Name

                      Address                                                                                Phone No.
                                          Administrative office where records are maintained
                      Location(s)
                                                Plant(s) or job site(s) of labor dispute, if other than above.

2.   Union:           Title and Local No.

                      Name and Title of Official

                      Address                                                                                Phone No.

                      On separate sheets list additional union(s), if any, directly involved. Also list separately union(s) not directly
                      involved. In both instances give job classification of workers they represent.

3.   Nature of business

4.   (a)      There is no labor dispute                               strike on                                                    and/or

     (b)      An interruption of work began because of a        lockout on                                          in a disagreement

     over:




5.   Job classifications of workers represented by the union directly involved in the labor dispute:




6.   (a) Normal number of workers                                              (b) Number of workers unemployed because of the strike
           at plant or job site________________________________                   or lockout

7.   Extent of curtailment in operations (manufacturing, volume or sales, etc,)                            %

8.   (a)      Not settled as of               (b)   Labor dispute settled on            (c)    Interruption of work ceased, pro-
                                                                                        ductive operations resumed on

     (d) If there was a delay between the date of settlement of the labor dispute and the date of resumption of productive oper-
          ations, give reasons for the delay:




                                                        (Continued on reverse side)
                                                                                                                     Ben-178A (9-91)
9.     (a)    Was there picketing?                  By Whom?                                                          How long?
       (b)    Was there force, violence, or other obstructive activities on the picket line?
              Describe such activity:


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10.    IMPORTANT, PLEASE NOTE:
       (a) Do you employ any workers who are NOT members of the union directly involved in the Labor Dispute?
                      yes                    no
       (b) If yes what are their job classifications?


       (c)    Did any of these workers refuse or fail to work?              Reasons given by them, if any, for such failure to work.

       (d)    Did they involve themselves in the labor dispute or strike activities, other than by refusing to cross the picket
              lines?                                   Please give specific facts or evidence.

       (e)    Could work have been provided for these workers in the absence of the workers directly involved in the dispute?
              If so for how long?
       (f)    Were any of these workers laid off?                  If so when?
       (g)    Please give the job classifications of any workers laid off:


11.    Did any workers continue in employment during this period?                      If so, what were their job classifications?


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NOTE:        Use additional sheets of paper if the spaces provided on this form are not sufficient to give all of the pertinent
             information.


                                    A copy of the labor management agreement will be appreciated.

I certify that the information contained herein is true and correct.                             Date

Signed                                                                         Title



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In addition to submitting this form, if you or any person designated by you has knowledge of the facts, wish to present
additional facts to the Claims Adjudicator in person, please check the box below. Your failure to request this opportunity will
not affect any established right you may have to file an appeal from any determination with which you may disagree.



      I wish to present additional facts to the Claims Adjudicator.



Arrangements will be made for interviews in Chicago regarding labor disputes in the Chicago Metropolitan Area or at one of
our downstate offices for those outside of such area, or at a location mutually agreeable.