This form should only be used for learners on the ESF Co-financing New Plan 2007/13. / Change notification / L/A03 Learner Reference Number
ESF SR – Part A – Learner Information
Section 1 – To be completed by the LEARNER – Please complete in BLOCK CAPITALS using Black Ink
L09 Learner’s Surname / L10 Learner’s Forenames / L11 Date of birth dd/mm/yyyy / L13 Sex (M or F)1 / 9
L18/L19
Address (current) / House No. / Name & Street / Suburb / Village
L20 / L21 / Town / City / County
L17 Home Postcode
(of Permanent Address Prior to enrolment) / L23 Contact Telephone No.
(inc STD Code)
L14 Learning Difficulties/Disabilities / Do you consider yourself to have a long term disability, health problem or any learning difficulties (Y/N/blank)
L15 Disability or Health Problem / L16 Learning difficulty / L12 Ethnicity
01 Visual impairment / 08 Temporary disability after illness e.g. post viral or accident / 01 Moderate learning
difficulty / 20 Autism spectrum disorder / 11 Asian or Asian British - Bangladeshi / 20 Mixed – White and Black African
02 Hearing impairment / 09 Profound complex disabilities / 02 Severe learning difficulty / 90 Multiple learning difficulties / 12 Asian or Asian British – Indian / 21 Mixed – White and Black Caribbean
03 Disability affecting mobility / 10 Aspergers syndrome / 10 Dyslexia / 97 Other / 13 Asian or Asian British – Pakistani / 22 Mixed – Any other mixed background
04 Other physical disability / 90 Multiple disabilities / 11 Dyscalculia / 98 No learning difficulty / 14 Asian or Asian British –
Other Asian background / 23 White – British
05 Other medical condition e.g. epilepsy / 97 Other / 19 Other specific learning difficulty / 99 Not known/information not provided / 15 Black or Black British – African / 24 White – Irish
06 Emotional / Behavioural difficulties / 98 No disability / 16 Black or Black British – Caribbean / 25 White – Other White background
07 Mental health difficulty / 99 Not known/information not provided / 17 Black or Black British – Other Black background / 98 Any Other
18 Chinese / 99 Not known/Not provided
Data Protection Act 1998 The personal information you provide is passed to the Chief Executive of Skills Funding and, where required, the Young People’s Learning Agency for England (“the YPLA”) to enable those organisations to fulfil their statutory obligations, principally under the Apprenticeships, Skills, Children and Learning Act 2009. Both organisations are registered as data controllers with the UK Information Commissioner’s Office. The Skills Funding Agency funds adult further education and skills training, including apprenticeships, in England . The YPLA is responsible for arranging the provision of funding for the education and training of young people in England . The Skills Funding Agency processes learner data on behalf of the YPLA. The information you provide may be shared with other organisations for purposes of administration, the provision of career and other guidance and statistical and research purposes, relating to education or training. Other organisations include the Department for Education, the Department for Business, Innovation and Skills, Local Authorities, Connexions, Higher Education Statistics Agency, Higher Education Funding Council for England , educational institutions and organisations performing research and statistical work on behalf of the Skills Funding Agency, the YPLA, or partners of those organisations. The Skills Funding Agency also administers the learner registration service (LRS) which uses your learner information to create and maintain a unique learner number (ULN). Further information about use of and access to your information is available at: Skills Funding Agency: YPLA: At no time will your personal information be passed to organisations for marketing or sales purposes. The YPLA, the Chief Executive of Skills Funding and their partners may wish to contact you from time to time in respect of surveys and research to monitor performance, improve quality and plan future provision and to inform you about courses, or learning opportunities relevant to you.
Tick this box if you do not wish to be contactedin respect of surveys and research by mail or phone.
Tick this boxif you do not wish to be contacted about courses or learning opportunities by post.
19 Mixed – White and
Asian
This activity is part-financed by the European Union through the European social Fund (ESF). ESF supports activities to extend employment opportunities and develop a skilled workforce.. /
L27a
L27b
Learner’s Signature / Date / 2 / 0
I certify that the information contained on this form is correct.
Version 4 –September 2010
/ Change notification / L09 Learner’s Surname / L10 Learner’s Forenames
N/A
ESF SR – Part B – Learning Aim Information
Section 2 – Learning Aim Start - To be completed by the PROVIDER at the start of the learning aim
L/A03 Learner ref. no. / L45/A55 Unique learner numberL01 Provider no (UPIN) / 1 / 1 / 9 / 4 / 4 / 9 / L46/A56 UK provider ref. no / 1 / 0 / 0 / 2 / 4 / 3 / 6 / 1
L35 Prior attainment level
What is the highest level achieved by the learner to date that is relevant to the sector or occupation / A09 Learning aim reference no. / X / E / S / F / 0 / 0 / 0 / 1 / A10 Funding model(tick applicable box)
Code 80 cannot be used for new starters / 70 / X / 80 / 81
A11 Sources of funding / N / / / A / A70 Contracting organisation code / S / F / A / N / E / A23 Delivery location postcode
A27 Learning start date / 20 / A28 Learning planned end date / 20 / A46 National learning aim monitoring / N / / / A
A49 Special projects & pilots / N / / / A / A63 National skills academy / N / A / A66 Employment status on day before starting learning aim / A67 Length of unemployment before starting ESF project
A61 Project dossier no (priority level) / 0 / 8 / 0 / 2 / 3 / L / N / E / 1 / A62 Local project number / 1 / 4 / 8 / A59 Planned credit value
Only required for QCF learning aims / N / / / A
I certify that the information contained in Section 2 is correct / Date / 20
Provider’s Signature / Print Name
Section 3 – Programme End - To be completed by the PROVIDER at programme end
A34 Completion status / A35 Learning outcome / A36 Learning outcome grade / N / / / A / L39 Destination / This activity is part-financed by the European Union through the European social Fund (ESF). ESF supports activities to extend employment opportunities and develop a skilled workforce.
A60 Credits achieved
Only required for QCF learning aims / N / / / A / A50 Reason learning ended / N / A / A31 Learning actual end date / 20 / A68 Employment outcome
I certify that the information contained in Section 3 is correct
/ 20
Provider’s Signature / Print Name / Date
Section 4 – Special Monitoring - To be completed by the PROVIDER
L41 Local learner monitoring
L42 Provider specified learner data
A47 Local learning aim monitoring
A48 Provider specified learning aim data
Version 4 –September 2010