PAC Participant Entry form
Part one: Summary
Delivery Organisation
Please choose a value
Blackburn with Darwen
Blackpool Coastal Housing
Calico
Community Gateway
Great Places
Inspire
Key Unlocking Futures
Lancashire Wildlife Trust
Lancashire Women
Newground
Onward / 1st Call
PAC
PVC
Princes Trust
Progress Housing
Regenda
West Lancashire
Title
Please choose a value
Mr
Mrs
Ms
Miss
Forename(s)
Surname
Gender
Please choose a value
Male
Female
Other
Date Of Birth
House Number
Address 1
Address 2
Address 3
County
Post Code
Home or mobile Number
Email Address
National Insurance Number
Start date with project
How did you find out about the project?
Please choose a value
Event Stall
Google Advert
Job Centre Referral
Leaflet
Newspaper/Magazine/Blog Article
Online Search
Poster
Printer Advert
Promotional Email
Promotional Text
Roller Banner
Sales Call
Social Media Advertisement
Social Media Post
Word of Mouth
Other
Part two: Eligibility
Have you been supported by any other European funded project in the past 12 months?
Please choose a value
Yes
No
To be eligible for support through More Positive Together we need to check that you have the legal right to live and work in the UK. Tick one box to confirm the item of evidence you are providing:
Please choose a value
Full passport (EU member)
Birth/ adoption certificate (EU member state)
N.I number - either plastic card or letter from HMRC
Full passport (not EU member)
Letter from UK immigration and nationality directorate granting indefinite right to remain
Residency permit for foreign nationals
Marriage/ civil partnership certificate (if partner has legal right to live in the U.K and this can be evidenced)
UK Driving License
Other
Please record the passport, birth/marriage certificate or residency card number:
Passport/residency card expiry date: (N/A for birth/marriage certificates)
Part three: Employment Status
Are you in paid work of any kind?
Please choose a value
Yes - Full time work
Yes - Zero hour contract
No
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Has Covid 19 effected your employment in anyway?
Please choose a value
Yes
No
If yes, How has Covid 19 effected your employment?
Are you currently looking for work/ required to look for work?
Please choose a value
Yes (not on benefits but looking)
Yes (On Jobseekers or Universal Credit)
No - Not on any Benefits
No - On ESA component of UC
No - Carer
No - Full time student
Are you currently in education or training?
Please choose a value
Yes - Full Time Education
Yes - Part Time Education / Training
No
Are you currently claiming any benefits?
Please choose a value
Yes
No
If Yes, which benefits:
IB/ESA or other sickness related benefit
Disability Living Allowance / PIP
Jobseeker's Allowance
Income Support
Universal Credit
Other (please state)
If other, please state
Part four: Ethnicity
Ethnicity
Please choose a value
White - English/Welsh/Scottish/Northern Irish/British
White - Irish
White - Roma, Gypsy or Irish Traveller
White - Other
Mixed/Multiple - White and Asian
Mixed/Multiple - White and Black African
Mixed/Multiple - White and Black Caribbean
Mixed/Multiple - Other
Asian/Asian British - Bangladeshi
Asian/Asian British - Chinese
Asian/Asian British - Indian
Asian/Asian British - Other
Asian/Asian British - Pakistani
Black/African/Caribbean/Black British - African
Black/African/Caribbean/Black British - Caribbean
Black/African/Caribbean/Black British - Other
Other Ethnic Group - Arab
Other Ethnic Group - Other Background
Participant Chose Not To Say
Do you identify yourself as being Cornish?
Please choose a value
Yes
No
Part five: Education
Select one option below for the highest level of education or qualification you currently hold:
Please choose a value
Below primary education (below isced level 1)
Primary education or equivalent (isced1)
Lower secondary education or equivalent (isced 2)
Upper secondary education or equivalent (isced 3) - GCSE
Post-secondary (non-tertiary education or equivalent (isced 4) - College
Tertiary education or equivalent (isced 5-8) - University
Do you hold an Entry, Level 1 (Grade D/E) or Level 2 (Grade C) Qualification in Maths?
Please choose a value
Yes
No
Do you hold an Entry, Level 1 (Grade D/E) or Level 2 (Grade C) Qualification in English?
Please choose a value
Yes
No
Do you hold an Entry, Level 1 (Grade D/E) or Level 2 (Grade C) in ESOL?
Please choose a value
Yes
No
Part six: Household situation
Are you currently homeless or affected housing exclusion?
Please choose a value
Yes
No
Prefer not to say
Do you currently live in a jobless household?
Please choose a value
Yes
No
Prefer not to say
Do you currently live in a jobless household with dependent children?
Please choose a value
Yes
No
Prefer not to say
Do you live in a single adult household with dependent children (lone parent)?
Please choose a value
Yes
No
Prefer not to say
Will you need childcare support/facilities if you embark on this project?
Please choose a value
Yes
No
Prefer not to say
Part seven: Other information
Are you an offender or ex-offender?
Please choose a value
Yes
No
Prefer not to say
Do you consider yourself to have a limiting long-term health condition or disability?
Please choose a value
Yes
No
Prefer not to say
Do you consider yourself to have a work limiting health condition?
Please choose a value
Yes
No
Prefer not to say
Are you substance misuse dependent?
Please choose a value
Alcohol
Drugs
Both
None
Other
Part eight: Participant Declaration
Participant Declaration (tick each box to confirm)
I know that the support I will be offered is funded by the European Social Fund.
The information provided in the form is, to the best of my knowledge, accurate.
I am not in paid work of any kind, including any zero hours contract.
If I have ticked a 'Participant chose not to say' option anywhere on this form, I confirm that I am refusing consent for this information to be collected.
I give permission for my personal details to be shared with the partners who are signatories to the Information Sharing Agreement involved in the delivery of this project.
I understand that this information will be retained until at least 31 December 2033 for evaluation purposes. After that time, it will be destroyed in a secure manner.
I may be contacted at any time to discuss my involvement in the project.
I understand that the DWP, Government Internal Audit Agency, AQA, Statutory bodies and signatories to the information sharing agreement may request to see this information at any time and that it can only be shared in a secure manner and never emailed
Participant Signed - Y/N
Please choose a value
Yes
No
Participant Signed - Date
Consent
PAC Participant Consent
I can confirm that I am happy to join the project and agree to the participant declaration
Full name of person providing consent
Clear
Submit