UC191 - Provider Refusal of Employment Referral form 
	Part 1: 	Participant Details	
	
	Participant name			
	
	Letters	 Numbers	 Letter		
	NI number			
	
	Telephone number		Mobile			
	
	 address	

		
	
	Employment Programme 			

	Part 2: 	Employment offer refused or failed to apply for	
	
	Job Title			
	
	Employer Name		Job Reference			
	
	Employer Address			
	
	Employer Contact		Contact Phone			
	
	Daily pattern of hours per
week	Mon		Tue		Wed		Thurs			
			
		Fri		Sat		Sun			
	
	Basic Wage	£	Per Week/Month/Year		

	Bonus and overtime	£	Per Week/Month/Year 		
	
	Is overtime available?	Yes		No			
	
	Bonus scheme details:			

	Was the job temporary?	Yes		No			
	From	To	
	If Yes what was the agreed term?															

	Closing Date	
	What was the vacancy closing date?								

	Part 3: 	Employment offer refused or failed to apply for (Continued)	
			
	What action was the participant required to carry out? (please select one of the below):		
	Date	Time	AM/ PM	
		Go to an interview arranged on							At:	:			
	
	Date	
		Apply for the detailed vacancy by (date):													
			
	How was the participant notified/ required to apply?: (As detailed on the MEN E.g. submit CV, online application or contact employer etc in relation to detailed vacancy).				

	Date MEN Issued	
	On what date did you notify the participant of what was required?								
	
	MEN issued by:	Hand:		Posted:			

	Part 4: 	What did the participant fail to do?	
	
	Did the participant (please select one of the below):		
	
		Fail to attend an interview?		
	
		Refuse to apply for the vacancy notified?		
	
		Fail to apply for the vacancy notified? 		
	
		Accept the vacancy offer but fail to start the job?		
	
		Fail to accept the vacancy when offered?		
	
		Fail to be offered the job due to their inappropriate actions?		
	Date	
	On what date did the above failure or refusal occur?								

	Was industrial action taking place at the company when the participant refused or failed to apply for the vacancy?	Yes		No			

	Date Started	Date Finished	
	If Yes between what dates?															

	Part 5: 	Participant Circumstances	
			
	Are you aware of any reason why the participant may not have fully understood what they were asked to do? (If Yes, give details below)	Yes		No			
	
	Additional Information	

	Part 6: 	Provider Details and Declaration	
	
	I certify the information given on this form is correct and the activity the participant was asked to undertake was reasonable taking into account their circumstances:	
	Date	
	Name of advisor/ tutor 					
	
	Email address of your
designated inbox			
	
	Provider name		Contact Phone			
		
	Provider address
(correspondence)

	Subcontractors ONLY Prime provider name