Title: ESF1420: European Social Fund Annex B Match
Author: Department for Work and Pensions
Last saved by: David Billany
Company: DWP

ESF1420: European Social Fund Annex B Match
Information Form

Part 1: | Participant Details
| Participant name | |
| Letters | Numbers | Letter |
| NI number | | | | | | | | | | | | | | | | | |
| Day | Month | Year |
| Telephone number | | Date of Birth | | | | | | |
| Participant address | |
| Post Code | |
| Start Date                                                                      PRAP P.O. No. | |
| Provider Name | |
| Postcode of the delivery location | |
| Male/ Female
1 | What is the participant’s gender? | |
| Employed/ Unemployed/ Inactive
2 | What was the participant’s status when provision started? | |
| | | Yes | | No |
3 | If unemployed was the participant long-term unemployed? | | | | | | |
| | Yes | No |
4 | Was the participant in education or training at Work Choice start? | | | | |
| ISCED Level 1-8
5 | What was the participants International Standard Classification of Education (ISCED) level when they started Work Choice? | |
| PNtS | Yes | No |
6 | Was the participant of a jobless household when they started Work Choice? | | | | | | |
| PNtS | | Yes | No |
7 | Was the participant part of a jobless household with dependant children at the start of Work Choice? | | | | | |
| PNtS | | Yes | No |
8 | Was the participant a single adult with dependant children? | | | | | |
| PNtS | Ethnicity (see list) |
9 | What is the participants ethnicity? | | | |
| PNtS | Yes | No |
10 | Does the participant consider themselves disabled? | | | | | | |
| PNtS | Yes | No |
11a | Does the participant have a defined ‘other disadvantage’? | | | | | | |
| Disadvantage Code (see list)
11b | If yes which disadvantage? | | | | |
| | Yes | N |
12 | Does the participant  have basic skills? | | | | |

Part 2: | How we collect, use and store information
To find out more about how DWP use information, read the DWP Personal information charter: https://www.gov.uk/government/organisations/department-for-work-pensions/about/personal-information-charter or contact any DWP office.

DWP may use the information you give us to:

•	Report and evaluate how well European Social Fund (ESF) programmes work* 
•	Link with other information we hold about you, if you are in receipt of a DWP working age benefit. 

* We may contact you again in the future to ask if you might participate in further evaluation. If you are re-contacted, you will still be able to decline to participate if you wish.

Part 3: | Participant Declaration (to be completed after the participant has read Part 1 and 2)

The information I have provided is current and correct to the best of my knowledge.

By signing this form, you:
•	Allow the Department for Work and Pensions (DWP) to store your basic personal information, included on this form, to make a referral to the Provider. 
•	Understand that the information may be used for other purposes relating to the work of the Department for Work and Pensions.
•	Understand that some information may be given to other government bodies as permitted by law.
•	Have been informed and understand that the activity delivered by the provider named on this form was funded by ESF, and have received leaflet ESF2020.
•	Understand that someone may contact you in the future to ask if you might participate in further ESF evaluation.

| Date
| Participant Signature | | | |

| Part 4: | Provider Details and Declaration (to be completed by the provider)
| I certify the information given on this form is correct to my knowledge:
| Date
| Name of advisor/ tutor: | | | |
| Signature: | |

Email address of 
designated inbox:

| Provider name: | | Contact Phone: | |
Please retain the original of this form in line with the retention policy in DWP generic guidance, chapter 11, and e-mail a copy to DWP.

ESF1420M (04/15) 			Page  of

Provider MAN (02/14)