Annex K Withdrawal Notification for LSC- funded Learners at Specialist Providers 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 principal/proprietor/owner. 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): Signed: Date: 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completion Destination data Please note that, in most cases, a destination data return is required where a learner has withdrawn from a programme before the funding end date agreed by the LSC.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 learner. 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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