Funding Contract Withdrawl by ejr35512


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									Annex K

Withdrawal Notification for LSC-
funded Learners at Specialist
This form should also be completed if a learner completes their programme
earlier than planned.
Reference: Rep/060577                   Confidential
(also available on the LSC website) For completion by the

1. Provider details

Name of provider (please print):

2. Learner details

Learners name (please print):
Date of birth:
Start date:
Agreed funding end date:
Withdrawal date:
3. Reason for withdrawal

Reason for withdrawal (please insert appropriate code from
attached list)
Details (please include all relevant information, for example dates, times,
action taken and links to any serious incidents

If a third party has been involved, please give further details.

4. Declaration
I am aware of the LSC’s policy regarding recovery of fees in accordance
with the LSC’s contract with specialist providers.

Name (please print):
Principal/owner/proprietor of provider
(delete as appropriate):

Please return the original to the relevant contact at the LSC.

Codes to use to indicate the reason for learner withdrawal

The code corresponding to the reason for withdrawal should be taken from
the following list and entered on the form in the box provided.

A       Alternative provision found

B       Learner no longer wishes to attend

C       Learner deceased

D       Learner failed to start

E       Learner unable to stay through injury
F     Learner found employment

G     Learner absent without leave

H     Learner excluded

I     Learner unable to stay through illness

J     Learner unhappy

K     Other

L     Early completion

Destination data
Please note that, in most cases, a destination data return is required where a
learner has withdrawn from a programme before the funding end date agreed
by the LSC.

Review reports
All withdrawal forms should be accompanied by a final review report for the

Serious incidents
Where a withdrawal has taken place as a result of a serious incident, please
note that this must be reported separately to the relevant LSC contact within
72 hours of the incident being made known to the provider (in accordance
with the LSC’s contract with specialist providers).

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