QUALIFICATION CONDITION NOT MET

Transcription

1 QUALIFICATION CONDITION NOT MET This form should only be used if you have not met the qualification condition on your registration. PART 1 PERSONAL DETAILS Full name Your SSSC Registration Number Part of the Register «Individual_Title» «Individual_First_Name» «Individual_Last_Name» «Individual_SCR_Number» «Register_Part» Condition End Date (DD/MM/YY) PART 2 ORGANISATION DETAILS Name of your organisation Please note any changes below <ENTER MANUALLY> Care Service Name and Number Please note any changes below <ENTER MANUALLY>

2 PART 3 REGISTRANT S SECTION A. REASON FOR NOT MEETING QUALIFICATION CONDITION Please provide a detailed explanation of why you have been unable to meet this condition. You should include supporting evidence where possible, which may include correspondence from your employer or training provider. If you do not provide us with this information we will be unable to consider your request for additional time to meet the qualification condition imposed on your registration:*

3 B. PERIODS OF TIME YOU WERE NOT WORKING TOWARDS YOUR QUALIFICATION START DATE END DATE REASON EXAMPLE 11/06/ /06/2014 Maternity leave. C. QUALIFICATION DETAILS Name of the qualification(s) you are working towards or plan to gain. Name of training provider The date you started or will start working towards this qualification Expected date of completion (DD/MM/YY) D. REGISTRANT S DECLARATION By signing this declaration, I declare that all the information I have provided on this form is correct to the best of my knowledge and belief. Print Name Signature Date (DD/MM/YY)

4 PART 4 EMPLOYER S SECTION A. EMPLOYER S SUPPORT I support «Individual_First_Name» «Individual_Last_Name» s request for additional time to achieve the qualification(s). Please state your reasons why you support «Individual_First_Name» «Individual_Last_Name» then complete sections 4B, 4C, 4D and 5:* I DO NOT support «Individual_First_Name» «Individual_Last_Name» s request for additional time to achieve the qualification(s). Please state your reasons why you do not support «Individual_First_Name» «Individual_Last_Name» then complete section 5:* B. VALIDATING THE REGISTRANT S INFORMATION Please read the following statements and if you agree with the information «Individual_First_Name» «Individual_Last_Name» has provided in Part 3 of this form please check the relevant boxes: I confirm the reasons and absence dates the registrant has provided for not meeting their condition is accurate. I confirm the name of the qualification(s) that the registrant is working towards or planning to achieve is correct. I confirm the start and completed dates the registrant has provided with regards to achieving the qualification(s) is correct.

5 C. ADDITIONAL INFORMATION If you have additional information that will contribute to «Individual_First_Name» «Individual_Last_Name» s case for additional time to achieve the qualification(s), please provide this:* D. SUPPORTING THE REGISTRANT TO ACHIEVE THE QUALIFICATION Please explain how you plan to support «Individual_First_Name» «Individual_Last_Name» to ensure they achieve the stated qualification within the timescale provided:* PART 5 EMPLOYER S/TRAINING PROVIDER S DECLARATION By signing this declaration I confirm that: As a countersignatory/senior representative for the above named organisation the information supplied in this form is true and accurate SSSC Countersignatory Pin Number (if applicable) Print Name Signature Date (DD/MM/YY) Work telephone Mobile telephone Work address E N D - The information contained within this form will be considered by the SSSC and the registrant will be informed of our decision in writing. *Please continue on a separate sheet if necessary. Each additional page should have the Registrant s full name and Registration number printed, and should be signed by both the Registrant and the Employer/Training provider.