This publication has been withdrawn. It is no longer current.				
Request to review a sanction for ESA participants only

Please note that this form may be shown to the participant
	
About the participant	

Participant’s Name  

Participant’s NINO                                                          Date of Birth
	
Details	

ESA participant had a sanction applied for failing to attend a mandatory interview with the Health Care Provider. I am now requesting that this decision be reviewed for the following reason:
( Please delete YES or NO as applicable)

Participant has now fully complied                                                                                YES/ NO                                                                                  

It is no longer appropriate for the participant to attend the interview                             YES/ NO

Participant has fully complied to attend an alternative interview                                   YES/ NO

I do not consider that participant has fully complied                                                      YES/ NO

Date they failed to attend the original Mandatory Interview

Date of compliance

Date of sanction decision (if known)

Dates of sanction              From                  	To
	
Compliance disputed	
A. What was the participant told to do and when? 	

	
B. What did the participant do or fail to do and when?	

	
C. Why do you consider that the participant has failed to attend the interview?  	

	

HCP09 Continued	
	
D. Why does the participant consider that they have completed the activity?	

	
Health Care Provider details	

I confirm that the above is a full and accurate statement

Name of HCP Contact   	Date

Email address                                                               Phone

Name of provider

Provider address

	
HCP09
Produced by the Department for Work and Pensions