Part 1: 	Participant Details (to be completed by the provider).	
	
	Participant name			
	
	Letters	 Numbers	 Letter		
	NI number																			
	Day	Month	Year		
	Telephone number		Date of Birth								
	
	Email address			
	
	Participant address	

				

	Participant Post Code			
	
	Contract ID			
	
	Provider Name			
	
	Category of Region			
	
	Postcode where the Participant Engagement Meeting will be held			
				
Part 2: 	Participant Characteristics (to be completed by the provider).	
		
1	What is the person’s gender?	Male	
Female
Participant chose not  to say		
		
2	Which of the following statements best describes the person’s Labour Market Status?
	Unemployed, excluding long-term unemployed (CO01)
Long-term unemployed (CO02)
Inactive (CO03)

3	Does the person have basic skills?	Yes	
No
Participant chose not  to say		
					
4	What is the person’s highest educational attainment?	Below Primary education (ISCED level 0) – Other disadvantaged
Primary education or equivalent (ISCED 1)
Lower secondary education or equivalent (ISCED 2)	
Upper secondary education or equivalent (ISCED 3)	
Post-secondary (non-tertiary) education or equivalent (ISCED 4)
Tertiary education or equivalent  (ISCED 5-8)		
					
5	Is the person engaged in education or training?	Yes	
No			
		
6	Is the person living in a Jobless Household?	Yes	
No
Participant chose not  to say		
					
7	Is the person living in a Jobless Household with dependant children?	Yes	
No	
Participant chose not  to say		
						
8	Is the person living in a single adult household with dependant children?	Yes
No
Participant chose not  to say		
						
9	What is the person’s ethnicity?	White - English/Welsh/Scottish/Northern Irish/British  
White – Irish
White - Roma, gypsy or Irish traveller
White – other
Mixed/Multiple - White and Black Caribbean
Mixed/Multiple - White and Black African
Mixed/Multiple - White and Asian
Mixed/Multiple – Other
Asian/Asian British – Indian
Asian/Asian British – Pakistani
Asian/Asian British – Bangladeshi
Asian/Asian British – Chinese
Asian/Asian British – Other
Black/African/Caribbean/Black British – African
Black/African/Caribbean/Black British – Caribbean
Black/African/Caribbean/Black British – Other
Other ethnic group – Arab
Other ethnic group - Other	
Participant chose not to say		
				
10	Does the person consider themselves disabled?	Yes
No
Participant chose not  to say		
					
11	Is the person an ex-offender?	Yes
No
Participant chose not  to say		
					
12	Is the person homeless?	Yes
No
Participant chose not  to say		

Part 3: 	Participant Eligibility (to be completed by the provider)	
	
	Please detail in the space provided below (max 80 characters) what evidence you have seen to confirm the individual named in Part 1:
•	is legally resident;
•	has the right to take paid employment in the UK; and
•	is aged over 16.	

		

Please detail in the space provided below (max 80 characters) what evidence you have seen and retained to confirm the individual named in Part 1 is;	
•	Unemployed* or
•	Inactive

	
	
	Please detail in the space provided below (max 80 characters) the eligibility category (as detailed in provider guidance) for which the individual named in Part 1 is being referred:	

		
	Please detail in the space provided below (max 150 characters) what evidence** you have seen and retained to confirm eligibility, including a self-declaration (where appropriate).	

		

*/** DWP will confirm the unemployed status, periods of unemployment or receipt of any qualifying benefits if appropriate.	

	
Part 4: 	How we collect, use and store information 	
	
To find out more about how DWP use information, read the DWP Personal information charter: https://www.gov.uk/government/organisations/department-for-work-pensions/about/personal-information-charter or contact any DWP office.

This charter includes the process for participants to make Right to Access Requests through their ESF 14/20 provider.  

To find out more about how DWP store and retain information read the following, ESF Guidance on document retention.

DWP may use the information you give us to:

•	Report and research how well European Social Fund (ESF) programmes work* 
•	Link with other information we hold about you, if you are in receipt of a DWP working age benefit. 

* We may contact you again in the future to ask if you might participate in further research. If you are re-contacted, you will still be able to decline to participate if you wish. For additional information on research and evaluation please see the following Gov.uk link, and select ‘Guidance on ESF and YEI Participant Contact Details’.  	
	
Part 5: 	Participant Declaration (to be completed after the participant has read Part 1, 2 and 3)	

The responses on this form accurately reflect those given to the provider.

The information I have provided is current and correct to the best of my knowledge and will be used by the provider named on this form to register me.

By signing this form, you:
•	Understand the Department for Work and Pensions (DWP) will store your basic personal information, included on this form, to make referral to the Provider
•	Understand that some information may be given to other government bodies as permitted by law.
•	Understand DWP may also share your personal information with the European Commission and Auditors (individual records may be requested to ensure that ESF programmes are being delivered appropriately).
•	Have been informed and understand that the activity delivered by the provider named on this form is funded by ESF, and have received leaflet ESF2020.
•	Understand that someone may contact you in the future to ask if you might participate in further ESF research.
•	Understand that where you receive benefit you must promptly tell the office that pays your benefit of anything that may affect your entitlement to that benefit, or the amount of that benefit you receive.
•	Understand that this ESF Provision is voluntary.
•	Agree to participate in this ESF Provision.	
							
	Print Name			
	Date	
	Participant Signature	

Part 6: 	Provider Details and Declaration (to be completed by the provider)	
	
	I certify the information given on this form is correct to my knowledge:	
	Date	
	Name of advisor/ tutor: 					
	
	Signature:	

	Email address of 
advisor/tutor:			

	Provider name:		Contact Phone:			
	
Please retain the original of this form