Form UC-15Q: Substance Abuse Information Sheet (Request for Recovery Efforts & Information) Logo
  • Form UC-15Q: Substance Abuse Information Sheet (Request for Recovery Efforts & Information)

    State of Connecticut Department of Labor, Employment Securing Adjudications
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  • Section 31-235 of the Connecticut Unemployment Compensation Law provides, in part, that an individual must be able and available for full-time work in order to be eligible for benefits.

    For those individuals whose job separations are attributable to alcohol or substance dependency, information pertaining to the individual’s ability to work as well as substantial steps the individual has made towards recovery must be obtained. Individuals with addictions to alcohol or drugs cannot be found able to work if they continue to engage in active drug or alcohol abuse. Benefits are reserved for those who have acknowledged their disease and are making good faith efforts toward recovery.

    The information requested on this form regarding the individual’s recovery efforts is essential for making a proper determination of eligibility for benefits. It is the responsibility of the individual to provide this information to the Adjudications Specialist by having the form completed.

    In instances where there is more than one person who can provide information regarding the individual’s recovery efforts, the form may be sent to all pertinent parties.

    This form is to be completed by an AA or NA sponsor, clergy person, group home chairperson or other knowledgeable third party who can verify both that the individual has abstained from drinking or using drugs and is engaged in on-going efforts to control the disease.

    The form is used when the individual asserts that he is clean and sober without having engaged in formal treatment and/or when the individual has completed a treatment program and is attending meetings as part of the after-care program. Information on the form is used to substantiate the individual’s rehabilitation and evidence of faithful participation in a program. It is essential to provide specific information regarding the individual’s attendance at meetings, counseling sessions or another program(s) as confirmation that the individual is in recovery.

  • Certification

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  • I hereby authorize the release of the information requested on this form to the Department of Labor. The information may be used to determine my eligibility for unemployment compensation benefits.

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  • Request for Recovery Efforts and Information

    (From an AA/NA Sponsor, Counselor, Clergyperson, or other knowledgeable third party)
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