ILR

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ILR

Please fill in your details below

ULN

Learner Reference

Lead Provider

Lead UKPRN

Delivery Partner

DP UKPRN

Family Name

Given Name(s)

Date of Birth

Age on 31/08/20

NI Number

Gender

Home Telephone

Mobile Number

Email Address

Emergency Contact Name

Relationship to you

Emergency Contact Number

Home Address

Previous Post Code (if lived at current address for less than 3yrs)

House hold situation

Have you been living in the United Kingdom or any other member state of the European Union for the last three years? (excluding holidays)

None

Yes

Were you born or do you have citizenship (hold a passport in) of either the United Kingdom or any other member state of the European Union/Area?

None

Yes

Please record the ID Seen

If other please specify

If you have NOT been resident in the EU or EEA for the past three years, please state the date you entered the UK

Visa No:

Immigration Status (e.g. asylum seeker, refugee)

Date of Expiry

Equal Opportunities Monitoring - This information is requested by the Educations & Skills Funding Agency and is for statistical monitoring - please select which one best describes you

Do you consider yourself to have a long-term learning difficulty, health problem or any learning difficulty?

None

Yes

Do you have from school a section 139A Learning Difficulty Assessment or Education Health Care Plan? (LDA)

None

Yes

Please state your primary disability:

Current Employment Status

Currently employed

Currently self-employed

Unemployed looking for work and available to start work

Unemployed not looking for work and / or not available to start work

If Employed - Is this a permanent contract?

None

Yes

How long have you been employed in your current role?

Contracted hours per week:

How many days of annual leave are you entitled to?

If you are self-employed - how long have you been self-employed?

If you are self-employed - what are your average weekly working hours?

Employer / Company Name:

Employer Head Office Address:

Employer Contact Name:

Employer Contact Number:

Delivery Site Address:

Delivery Site Contact Name:

Delivery Site Contact Number:

Delivery Site Contact Job Title:

No. of employees across whole organisations:

EDRS Number:

If unemployed - How long have you been unemployed?

Are you currently in receipt of any government benefits?

None

Yes

Which benefits are you currently claiming?

Job Seekers Allowance (JSA)

Employment & Support Allowance (ESA WRAG)

Universal Credit

If you are claiming any other form of benefits, please specify:

Are you currently enrolled with any other College or Training Provider?

None

Yes

If yes, please state the date you started

If yes, please state the course title

If yes, please state the date you left

Please list your prior qualifications. If you have NO prior qualifications, please state that in this box

English Language GCSE - Please state the grade and date achieved

English Literature GCSE - Please state the grade and date achieved

Mathematics GCSE - Please state the grade and date achieved

Functional Skills English - Please state the grade and date achieved

Functional Skills Maths - Please state the grade and date achieved

Key Skills Communication - Please state the grade and date achieved

Key Skills - App of Number - Please state the grade and date achieved

Other Qualifications (GCSE, A Level, GNVQ, NVQ) record name, grade or level and date achieved

Any degrees or qualifications at level 4 or above? (If yes list below)

Highest Prior Attainment Level:

Initial Assessment Results - English. Please state the IA type (paper or online), Result, Outcome Level and Date Completed

Initial Assessment Results - Maths. Please state the IA type (paper or online), Result, Outcome Level and Date Completed

Initial Assessment Results - ICT. Please state the IA type (paper or online), Result, Outcome Level and Date Completed

Availability for Learning - Please let us know when you will be available for learning each day (Monday-Sunday). Please include any shift variation or access restrictions. E.g. I will be available Mondays 10am-3pm, Tuesdays 12pm-5pm, etc.

Please list any potential barriers to learning/ gaining employment:

First Language, if other than English (information optional)

Please detail learners’ suitability for enrolment on programme: Please include details of alternative appropriate qualifications, reason for decision of chosen programme level, the benefits to the learner and employer (if applicable) of completing the programme.

Justification of a second qualification at the same level: (if applicable) (To be completed where learner has previously achieved an NVQ or Apprenticeship and would like to complete a qualification at the same or lower level)

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