Shetland Pathways to EmploymentReferral Form

Referral Agency Details
Referring Agency
Agency Worker Name / Agency Worker Role
Address / Tel No: (Work)
Mobile: (Work)
Postcode / Email Address:
Participant Details:
Name / Employment Status / UnemployedLong Term UnemployedEconomically InactiveInactive, not in Education or TrainingEmployed or Self-Employed
Address / Date of Birth
Home Phone
Post Code / Mobile
NI Number / Email
Gender / MaleFemale / Current Nationality
Does the participant hold an active GIRFEC or WYFI? / YesNo
Details of Benefits
If possible, please provide full details of the customer’s current claim(s). This is likely to increase their eligibility to receive support from the Shetland Employability Pathway.
Benefit Type (e.g. UC with a breakdown of all elements: JSA; ESA; HB; IS etc.) / Claim Start Date / Benefit Type (e.g. UC with a breakdown of all elements: JSA; ESA; HB; IS etc.) / Claim Start Date
Date identified for referral to work programme (if applicable)
Potential Barriers to Employment (please select all that are applicable)
Long-term Unemployment (Aged up to 24; Unemployed; JSA, UC or ESA WRAG, 6 months+) / Low skilled (ISCED Level 2 or below) / Long-term physical illness
Long-term Unemployment (Aged 25+; Unemployed; JSA, UC or ESA WRAG; 12 months+) / No experience of paid employment / Homeless or affected by housing exclusion
Substance issues (incl. alcohol) / Criminal convictions (any crime that an individual has been convicted of that has not been spent or is exempt from becoming spent) / Migrant, people with a foreign background, minorities (including marginalised communities such as Roma)
Primary carer of a child/children (under 18) or adult / Disabled / Living in a jobless household and:
Primary Carer of person over 65 / Asylum seeker / a) At least 2 jobless adults, no dependent(s)
Mental health issues / Refugee / b) At least 2 jobless adults, with dependent(s)
Armed Forces Veteran / Looked after young person / c) Single adult household, with dependent(s)
From Employment Deprived Areas / Above 54 years of age / d) Single adult household, no dependent(s)
Poor accessibility to services / From Rural Areas (outwith Lerwick)
Please provide any supporting information to explain why you believe the customer to have these barriers. Evidence of barriers will be required i.e. – official letter/copy of benefits and Bank statements.
Additional Information
Length of time since the participant last worked (years and months)
Description on progress made with referring agency (please detail any relevant information):
Please detail below any additional information eg personality, past history, home and family life, emotional support needs, goals for the future and any other relevant information:
Justification as to why the Participant has been referred:
Details of all other agencies involved with the Participant
Agency / Name / Contact Numbers

Participant: I hearby give full consent to share my details specific to me obtaining employment.

Signature: ...... Date:......

Signature of Representative from Referring Agency: ...... Date: ......

The Shetland Islands Council is registered as a Data Controller in terms of the Data Protection Act 1998. The information provided by you will beused for the purpose of Shetland Employability Pathway, and for no other purpose. The information will not be shared with partners outwith the pathway or used for any other purposes, without your explicit consent.

Referral_Form_v2_June 2016