EWC Logo

EWC / CGA

Fitness to practise banner
Employer and Agent referral form
Employer and Agent referral form

Referral form for use by employers and agents for referring allegations of unacceptable professional conduct (UPC), serious professional incompetence (SPI), conviction of a relevant offence (RO)

Please read this form carefully, including the Guidance and notes, section before making a referral.

Part 1: Details of the registrant you are referring

A. Personal information (as known)

Invalid Input
Invalid Input
Invalid Input
Invalid Input
Invalid Input
Invalid Input
Invalid Input
Invalid Input
Invalid Input
Welsh-speaker (Y / N)
Invalid Input

B. Contact details of the registrant you are referring

Invalid Input
Invalid Input
Invalid Input
Invalid Input
Invalid Input

Part 2: Details of the work carried out by the registrant you are referring

C. About their role

Invalid Input
Invalid Input
Invalid Input
Invalid Input
Invalid Input
Invalid Input
Invalid Input

D. Please give details of any previous alleged misconduct, incompetence, disciplinary action or complaints (including any previous referrals to police, DBS or any other regulatory body).

Invalid Input
Invalid Input
Invalid Input
Invalid Input
Invalid Input
Invalid Input
Invalid Input
Invalid Input
Invalid Input
Invalid Input

Part 3: Details of the allegations of unacceptable professional conduct (UPC), serious professional incompetence (SPI), conviction of a relevant offence (RO)

Invalid Input

Part 4: Chronology of events (including details of all local procedures followed)

F. Please set out the events relating to this referral in the order in which they happened

Invalid Input
Invalid Input
Invalid Input
Invalid Input
Invalid Input
Invalid Input
Invalid Input
Invalid Input
Invalid Input
Invalid Input
Invalid Input
Invalid Input
Invalid Input
Invalid Input
Invalid Input
Invalid Input
Invalid Input
Invalid Input
Invalid Input
Invalid Input
Invalid Input
Invalid Input
Invalid Input
Invalid Input
Invalid Input
Invalid Input
Invalid Input
Invalid Input
Invalid Input
Invalid Input
Invalid Input
Invalid Input
Invalid Input
Invalid Input
Invalid Input
Invalid Input
Invalid Input
Invalid Input
Invalid Input
Invalid Input
Invalid Input
Invalid Input
Invalid Input
Invalid Input
Invalid Input
Invalid Input
Invalid Input
Invalid Input
Invalid Input
Invalid Input
Invalid Input
Invalid Input
Invalid Input
Invalid Input
Invalid Input
Invalid Input
Invalid Input
Invalid Input
Invalid Input
Invalid Input
Invalid Input
Invalid Input
Invalid Input
Invalid Input
Invalid Input
Invalid Input
Invalid Input
Invalid Input
Invalid Input
Invalid Input
Invalid Input
Invalid Input
Invalid Input
Invalid Input
Invalid Input
Invalid Input
Invalid Input
Invalid Input
Invalid Input
Invalid Input

Part 5: Documentation supplied

Please note that the list below is not intended to be a definitive list of information and evidence to be forwarded with the referral. It is a guide to the most common documents used in local level disciplinary procedures that would be useful for EWC’s investigation. See the ‘Guidance and notes’ section for more information on what to include with a referral.

<h3>G. Please use the tick boxes below to show the types of documentation you are supplying with this referral. </h3>
Invalid Input
Invalid Input

H. If any relevant documents have not been supplied, please state reasons. For example, if documents are missing or to follow. Please list those documents.

Invalid Input
Invalid Input
Invalid Input
Invalid Input
Invalid Input
Invalid Input
Invalid Input
Invalid Input
Invalid Input
Invalid Input
Invalid Input
Invalid Input
Invalid Input
Invalid Input
Invalid Input
Invalid Input
Invalid Input
Invalid Input
Invalid Input
Invalid Input

Part 6: Referring party

I. Referring organisation / establishment

Invalid Input
Invalid Input
Invalid Input
Invalid Input
Invalid Input

J. Primary contact

Invalid Input
Invalid Input
Invalid Input
Invalid Input
Invalid Input
Invalid Input
Invalid Input

K. Alternative contact

Invalid Input
Invalid Input
Invalid Input
Invalid Input
Invalid Input
Invalid Input
Invalid Input

L. Names and contacts of key witnesses in this referral

Invalid Input
Invalid Input
Invalid Input
Invalid Input
Invalid Input
Invalid Input
Invalid Input
Invalid Input
Is this witness registered with the EWC?
Invalid Input

Additional key witness

Invalid Input
Invalid Input
Invalid Input
Invalid Input
Invalid Input
Invalid Input
Invalid Input
Is this witness registered with the EWC?
Invalid Input

Additional key witness

Invalid Input
Invalid Input
Invalid Input
Invalid Input
Invalid Input
Invalid Input
Invalid Input
Is this witness registered with the EWC?
Invalid Input

Additional key witness

Invalid Input
Invalid Input
Invalid Input
Invalid Input
Invalid Input
Invalid Input
Invalid Input
Is this witness registered with the EWC?
Invalid Input
Invalid Input

Part 7: Declaration – to be signed by the person making the referral

  • I confirm that the contents of this form are true to the best of my knowledge and belief.

  • I understand that a copy of this form and any enclosures will be disclosed to the registrant in accordance with EWC’s Disciplinary Procedures and Rules.

  • I confirm that I have obtained any necessary permission from third parties for the documents to be disclosed, including Part IV Strategy Meeting Minutes, police information, audio and video files.

  • I understand that I may be required to attend a hearing of a Fitness to Practise Committee to give evidence, should this referral reach that stage.
Invalid Input
Invalid Input
Invalid Input
Invalid Input
Invalid Input
Invalid Input
Invalid Input

After pressing SUBMIT, you will receive an email explaining how to provide the referral documents / evidence by email to the EWC