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Part 1: Customer Details

							

	
	
Part 2: Provider Details

Part 3: Details of the MWA referral

			

Part 4: Reason for Dismissal through Misconduct

Please give reason for dismissal (attach additional sheets if necessary)

Did the customer explain their actions?
	
If yes, please give details

Was the customer warned prior to dismissal?

Please state the date on which the warning was given and if it was written or oral.  Please attach a copy of any written warnings, and if the dismissal was notified in writing, please attach a copy of the dismissal letter.

Date:					

Please use the space below to provide any other information that you think may complete the picture of the events leading up to and including the customer’s dismissal.

Please go to part 6

Part 5: Reason for failing to Comply

If customer has given a reason for giving up a place early or failed to start / attend MWA, please provide reasons below.

Please use the box below to provide any other relevant information. 

Part 6: Declaration

I certify that the information given on this form is correct. 

Name							Signed

Position						Telephone

Date

This document should not be e-mailed – printed / fax referrals to be sent only.

Completion Notes

General
1.	Please complete this form and return to your allocated DMA office (within 2 working days). 
2.	Your reply may be shown to the customer or anyone acting on their behalf. 
3.	Decision Maker may write to you again if further information is required. 
4.	Please use BLACK ink and capital letters throughout, and tick all boxes that apply.

Part 1
1.	Input customer details.

Part 2
1.	Input Provider details.

Part 3
1.	Input the date the customer was notified i.e. the date the notification letter was issued.
2.	Input the dates the customer was required to attend i.e. the first date the customer was required to attend and the last date the customer was required to attend. 
3.	Input the date the customer failed to participate.
4.	Input the name and address of the placement organisation. 
5.	Select the appropriate box.

Given up a place on MWA – select this option if the customer has started the placement and subsequently gave up the place e.g. leaves voluntarily and never returns.
Lost a place on MWA through misconduct – select his option if the customer’s behaviour is such that effective participation in the scheme is not possible (you must discuss with the JCP prior to any dismissal due to misconduct).
Failed to Attend MWA – select this option if the customer does not start MWA at all. 

Part 4
This part should only be completed if the customer has failed to participate due to misconduct.
1.	Input the reason the customer has been dismissed due to misconduct.  Provide as much information as possible relating to the circumstances surrounding the dismissal to allow the Decision Maker to make a timely decision.  If the customer gave an example of their actions provide this information also. 
2.	Select the appropriate tick box.
3.	If a warning was given provide the date this was given and select whether the warning was written or oral.
4.	Include any further information which may assist the Decision Maker in making a decision.
Go to part 6

Part 5
This part should only be completed if the customer has failed to participate because they failed to start or started and then gave up a place. 
1.	Input the reason the customer has given for giving up a place following a start or for failing to attend (i.e. not starting)
2.	Include any further information which may assist the Decision Maker in making the decision. 

Part 6
1.	Input the name, position in the company and telephone number of the person completing the form and sign the form prior to return. 

To return the form please follow the Provider Generic Guidance Chapter 8 (Sending Information) and guidance contained in the MWA Provider Guide.