ESF Co-Financing

Participant Information Form

Could you please provide the information as requested on the following form. The form is to be filled in by people who are registered on a support & training course co-funded by Luton Borough Council and the European Social Fund (ESF).

To complete the form, you will need the name and the reference number of the course you are attending. This information will be given to you by your training provider.

Please note that your rights to confidentiality are protected under the Data Protection Act, 1998. The information you provide will be stored by the Council and used to compile anonymous statistics to inform the Council and its funding partners.

Project Name
Project Number

First Name(s)______

Surname______

Address______

______

Post Code______

Phone no______

Email address______

Date Joined Project______

Gender

MaleFemaleTransgender

Sexuality

HeterosexualGay/LesbianBisexual

Prefer not to say

Date of Birth

Day ______Month ______Year ______

Employment Status

Currently in full time employment Yes

(If Yes, are you threatened with redundancy?Yes )

Currently in part time employment Yes

(If Yes, are you threatened with redundancy?Yes )

At School or in full-time education Yes

Aged 14 – 19 not in education, employment or training?Yes

Registered Jobseeker Yes

(If Yes, for how many weeks ______)

On incapacity / inactive benefitYes

Other (e.g. carer / retired) ______

Religion

Buddhist

Christian

Hindu

Jewish

Muslim

Sikh

None / Atheist

Other (please specify) ______

Prefer not to say

Ethnic Background

White – British

White – Irish

White – other EU

Traveller / Gypsy

White – Other (please specify) ______

Mixed – White and Black Caribbean

Mixed – White and Black African

Mixed – White and Asian

Mixed – Other

South Asian or Asian British – Indian

South Asian or Asian British – Pakistani

South Asian or Asian British – Bangladeshi

South Asian or Asian British – Other

Chinese

Black or Black British – Caribbean

Black or Black British – African

Black or Black British – Other

Other (please specify) ______

Prefer not to say

Disability

Would you class yourself as disabled? Yes

If Yes, are you:

Hearing impaired / Deaf

Visually impaired / Blind

Other Physical Disability

Mental Health Issues

Learning Difficulties

Other work limiting illness (please specify) ______

Educational Level (highest achieved). Do you have:

No formal qualifications

NVQ Level 1 (e.g. GCSEs Grades D – G )

NVQ Level 2 (e.g. GCSEs Grades A* – C )

NVQ Level 3 (e.g. A Levels)

NVQ Level 4 (Certificates of higher education) or over

Is English your first or main language? Yes No

Other Information. Are you:

Lone Parent / Carer? Yes

Ex-Offender? Yes

Homeless? Yes

On a Drug or Alcohol Treatment Programme?Yes

Recent Migrant to the UK? Yes

Have refugee status (with permission to work)? Yes

“Soft Skills” – Please indicate status on Joining

Skill / Level 1 (low) / Level 2 / Level 3 / Level 4 / Level 5 (high)
Self Confidence / Self Esteem
Numeracy
Literacy
Problem Solving
Communication skills
Aspiration / Motivation

I confirm that the above details are correct.

Signed______Date ______

ESF Co-Financing – Participant Form v. 4/12/09Page 1