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     MWA1UC(email)   	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 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