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Document Number: UCB-18106-E
Description: Substance abuse treatment provider uses this form to notify the Department of Workforce Development, Unemployment Insurance Division (DWD/UI) of an individual's compliance or non-compliance with treatment each week. The week for certifying compliance runs Sunday to Saturday.
Comments: Please return completed form by mail, fax or encrypted email within 7 days of the end of the week to: Unemployment Insurance, P.O. Box 7905, Madison, WI 53707, Fax: (608) 260-2506, Email: UIDrugTest@dwd.wi.gov. Failure to return the form could result in denial of benefits to the claimant and no payment for services will be processed.
This form is available as an electronic Microsoft Word document that can be filled out on your computer to save and email, or it can be printed and then mailed or faxed. If you are unable to use the Microsoft Word document, a fillable PDF is also provided that can be printed and then mailed or faxed.
Content Contact: UI Pre-Employment Drug Screening Notification
Document Attachments:
UCB-18106-E (Electronic Microsoft Word Version - doc/71 KB)
UCB-18106-E (Electronic Adobe Version - pdf/20 KB)
NOTE: When using Google Chrome, you may notice overlapping text when you select file, print. Deselect the 'fit to page' option and the text will no longer overlap.
Note: If you need this form in an alternate format, please send a message to the Content Contact listed above.
DWD Contact Information
201 E. Washington Ave
P.O. Box 7946
Madison, WI 53707
(608) 266-3131
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