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     MWA1UC   	Mandatory Work Activity DMA Sanctions Referral Form

Part 1: Claimant details

							

First name(s):

National Insurance number:

	
	
Part 2: Provider details

Part 3: Details of the MWA referral

The claimant was told on:			

To fully take part in a placement 
starting on:

The claimant did not fully take part on:

Nature of the failure to fully take part in MWA:
 
Lost a place through misconduct (go to part 4)

     		
 
Gave up a place on, or did not attend MWA (go to part 5)

	
     
Part 4: Misconduct (for example, inappropriate behaviour or not meeting a requirement)

Please give details (attach additional sheets if necessary)

Did the claimant explain their actions?

If yes, please give details

Was the claimant warned prior to dismissal?

Please state the date on which the warning was given and if it was written or oral.  

Date:					

Please attach a copy of any written warnings. If the dismissal was given in writing, please attach a copy of the dismissal letter.

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 claimant’s dismissal.

Go to part 6

Part 5: Gave up a place or did not attend

If the claimant has given a reason for giving up a place early, or failing to start or attend MWA, state the reason 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

Completion Notes

General
1.	Please complete this form and return to Universal Credit within 2 working days. 
2.	This form may be shown to the claimant or anyone acting on their behalf. 
3.	The Decision Maker may contact 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.	Enter claimant details.

Part 2
1.	Enter provider details.

Part 3
1.	Enter the date the claimant was told about the placement (i.e. the date the notification letter was issued)
2.	Enter the dates the claimant was required to attend (i.e. the first date the claimant was required to attend and the last date the claimant was required to attend. )
3.	Enter the date the claimant did not fully take part.
4.	Enter the name and address of the placement organisation. 
5.	Select the appropriate box.

Lost a place on MWA through misconduct – select this option if the claimant’s behaviour means that effective participation in the scheme is not possible (you must discuss this with the Universal Credit before any dismissal due to misconduct).

Gave up a place on, or did not attend MWA – select this option if:

•	the claimant started the placement and subsequently gave up the place (for example, they left voluntarily and never returned)

•	the claimant did not start MWA at all

Part 4
This part should only be completed if the claimant has been dismissed due to misconduct.
1.	Enter the reason the claimant has been dismissed due to misconduct.  Provide as much information as possible about the circumstances surrounding the dismissal, to allow the Decision Maker to make a timely decision. If the claimant gave an explanation for their actions provide this information too. 
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 help the Decision Maker to make their decision.

Go to part 6

Part 5
This part should only be completed if the claimant did not start or started and then gave up a place. 
1.	Enter the reason the claimant has given for leaving or not starting a placement
2.	Include any further information which may help the Decision Maker to make their decision. 

Part 6
1.	Enter 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 follow the Provider Generic Guidance Chapter 8 (Sending Information) and also guidance in the MWA Provider Guide.