Department for Work and Pensions
This publication is withdrawn. This publication is no longer current.
DMA 02 (UC) - Misconduct Referral – ELR (S&W) for UC Claimant	
Please note that this form may be shown to the claimant

| Part 1: | Claimant details
| Claimant’s name | |
| Letters | Numbers | Letter |
| NI number | |
| Telephone number | | Mobile number | |
| Claimant’s address | |
Complete Part 2

| Part 2: | Reasons for dismissal through misconduct
| Date
| After discussion with UC the claimant was dismissed from ELR (S&W) on | |
| Please give reasons for dismissal: |
| Yes/ No
| Was the claimant warned prior to dismissal? | |
| Written/ Oral | Date issued
| If yes, when was the warning issued and was the warning written or oral? | | | |
| Please use Part 3 to provide any further information that you think may complete the picture of the events leading up to the claimant’s dismissal, including any reason the claimant may have given for their actions or failure to act. |
Complete Part 3
| Part 3: Further information
| Where appropriate, in the space below please provide any further relevant information that may assist the decision maker in making the decision.
Complete Part 4

| Part 4: Provider Details and Declaration
| I certify the information given on this form is correct and the activity the claimant was asked to undertake was reasonable taking into account their circumstances:
| Date
| Name of advisor/ tutor | | | |
| Provider name | | Contact Phone | |

Provider address
(correspondence)

| Subcontractors ONLY Prime provider name | |

How to complete the ELR (S/W) UC DMA 02:

Part 1: Claimant Details.
Please enter the participant's full name, National Insurance number, telephone number and address in the fields provided. (Please Note: The address field must detail the address to where any posted mandation notifications have been sent).

Part 2: Reasons for dismissal through misconduct.
Please enter the date (once agreed with JCP) that the claimant was dismissed from ELR (S/W) and please provide detail and reasons for dismissal. E.g. consistent unacceptable behaviour etc. (Further information regarding unacceptable behaviour can be found in Section 4 of the ELR (S/W) Provider Guidance). 

Please also provide any detail of any warnings prior to dismissal and if these warnings were written or oral.  

Part 3: Further information.
Please provide any further relevant information that may assist the decision maker in making the decision that you think may complete the picture of the events leading up to the claimant’s dismissal, including any reason the claimant may have given for their actions or failure to act.

This may also include:
 
•	Further information regarding any warnings given to the claimant prior to dismissal.
•	Statements provided by the host employer regarding the claimant dismissal.
•	Any history of previous compliance or non-compliance that is relevant to this referral.

You must include details of the original Mandatory Activity Notification (MAN) issued to the claimant such as:

•	Date MAN issued
•	Method of issue
•	Date of the mandatory activity
•	Time of the mandatory activity
•	Give full details of the mandatory activity

Please Note: You should also note here where you have mandated the claimant to maintain basic standards of good behaviour.

Part 4: Provider Details and Declaration
Please enter the contact details of the person/provider completing the form and by so doing, you are confirming that the form has been completed fully and accurately.

ELR (S&W) UC DMA 02		Page  of

Provider MAN (02/14)