Surrey Lifelong Learning Partnership | Community Learning Champions | Champions Inspire Activity Record Sheet for Individual Learner Interventions

1. Learner contact details
?	Community Learning Champion (CLC) name: *
?	Learner name: *
?	Town or postcode:
2. Record of intervention
?	Date of intervention (dd/mm/yyyy) *
?	Please select one type of intervention: *	A. Face to face initial contacts where information was provided B. Interviews to identify informal adult learning needs, interests and appropriate activities C. Practical support to start informal adult learning D. Practical support to sustain informal adult learning E. Signposting and referrals to informal adult learning activities F. Signposting and referrals to formal adult learning activities G. Signposting and referrals to information, advice and guidance services
?	Brief details of the intervention (eg signposted to ACL literacy course; enrolled on first aid course; provided details of childcare NVQ): *
3. Information about this learner (Note: This information will be anonymous and will be detached from the learner’s record)
?	3.1 Gender *	Female Male Trans Prefer not to say Not known
?	3.2 Age *	19-24 25-49 50-74 75+ Prefer not to say Not known/not provided
?	3.3 Disability Does the person consider him or herself to have a disability? *	Yes No Prefer not to say Not known/not provided
?	3.4 Ethnicity *	Asian or Asian British - Bangladeshi Asian or Asian British - Indian Asian or Asian British - Pakistani Asian or Asian British – any other Asian background Black or Black British - African Black or Black British – Caribbean Black or Black British – any other Black background Chinese Mixed – White and Asian Mixed – White and Black African Mixed – White and Black Caribbean Mixed – any other mixed background White – British White - Irish White –any other white background Any other Not known / not provided
?	3.5 Employment status *	Currently in paid work / employed Currently in paid work / self employed Not in paid work In full time education Not known/information not provided
?	3.6 Care responsibilities *	Child care Elder care Other dependant care No caring responsibilities Not known

Champions Inspire Activity Record Sheet for Individual Learner Interventions

Champions Inspire Community Learning Champions are asked to use this simple online form to keep a record of their one-to-one interventions with one learner.