Case Form
For members, representatives, branches and regions
FILE NUMBER FOR REGIONAL USE ONLY
CASE TYPE SUB TYPE
FOR THE MEMBER TO FILL IN
Conditions for providing assistance
1. UNISON seeks to ensure that members are provided with the representation has been withdrawn. Nor will UNISON be
best possible advice and assistance to achieve a satisfactory responsible for providing assistance in respect of any appeal or
outcome to matters of grievance and discipline. UNISON will higher level hearing against a decision arising from
determine the most appropriate representative for your case. representations made after you have opted out from UNISON
This may mean reallocating the case at a later stage and you will assistance or after UNISON assistance has been withdrawn.
be informed of any such decision.
7. You are expected to cooperate with your representative by
2. UNISON representatives and members are expected under being honest and frank about any allegation against you and in
UNISON rules to treat one another with respect. Failure to do so respect of any grievance you have. Your representative can only
by a UNISON representative will entitle you to make a complaint assist you if they are in possession of the full facts. Failure to
in accordance with UNISON’s Complaints Procedure: cooperate can lead to UNISON support being withdrawn.
www.unison.org.uk/upload/sharepoint/
Policies/COMPLAINTS_PROCEDURE.pdf. Failure by you to 8. You must notify your representative immediately if your
treat your representative with respect may lead to support being circumstances change or if any new information comes to light
withdrawn from you. regarding your case.
3. At all times, action taken on your behalf will be on the basis of 9. You must ensure that your personal and financial information
agreement reached between you and your representative about is accurate and up to date at the time that you apply for
the best way UNISON can assist you. Throughout the procedure assistance. You must also confirm that your UNISON
you will be kept informed and no decision will be made without subscriptions are up to date. If you have given information which
first consulting you. Should you decide at any point not to accept is misleading UNISON has the right to withdraw support.
the advice of your UNISON representative then you are free to
proceed without UNISON assistance. Please inform UNISON if
10. In the event of UNISON support being withdrawn you have
you no longer require UNISON’s assistance in these
the right to appeal to your branch secretary in the first instance
circumstances.
unless notified otherwise.
4. The Declarations at Section 12 must be signed if a potential
11. You must remain a member of UNISON throughout any
legal claim is identified. UNISON supports claims to an
period during which UNISON is providing advice and assistance
Employment Tribunal, where a legal claim has been assessed
to you. This means that if you are unemployed by reason of
by our solicitors as having reasonable prospects of success.
dismissal or redundancy you must pay a UNISON subscription
at the Unemployed Member’s rate; if you gain new employment
5. Until UNISON or its solicitors confirms in writing that it is within or outside of the areas of UNISON organisation you must
acting for you in a legal claim, any responsibility for lodging a maintain a UNISON subscription according to your earnings
claim in an Employment Tribunal or Court (including County band as set out in Schedule A of the UNISON Rule book.
Courts, Sheriff Courts and appeal Courts) is yours alone.
12. UNISON reserves the right to use the details of your case
6. UNISON representation is provided on the understanding that and outcome in publicity, case study or learning materials,
UNISON is your sole representative. UNISON cannot be held subject to your name only being used with your permission.
responsible for any costs or expense incurred if you have opted
out from UNISON assistance or if UNISON
Please ask the Branch to copy this form for you and note the contact details below
Your case has now been referred to the UNISON representative The name of your UNISON rep is:
whose name and contact details are recorded below. Assistance
will be provided in accordance with UNISON’s scheme for Work telephone:
representing members and the conditions outlined overleaf.
Mobile:
If, following your initial discussions, it is agreed that the
representative will act on your behalf, any action will normally be
Email:
done in consultation with yourself. Your representative should
Work address:
keep you routinely informed of any developments, and you should
note short periods of non-communication may simply mean that
your representative is waiting for someone (for example an
employer, a witness) to respond to a letter or message. Please
respect that most lay officers are doing a voluntary job in their own
Regional contact:
time. However, if necessary, please feel free to contact your
representative to avoid undue stress to yourself.
Case Form
This information will 1. Membership details
be used to ensure that
you are eligible for Membership No: 22311402 Please give the date you joined: 16/11/2024
support.*
This information will 2. Member’s correspondence details
be used to contact
Title: MRS First name: SHEILLA Surname: NSOR
you and to update
your membership Address: LS9 8QQ 21 CLARK ROAD
record. It will also be
provided to an Postcode: LS9 8QQ
Employment Tribunal
or court if UNISON
agrees to pursue your 3. Member contact details
case.* Home phone: Work phone:
Mobile: 07742726524 Work email:
Voice/Text no: Home email:
Please provide 4. Member personal details
information of any
Date of birth: 27/11/1994 Gender: FEMALE
disability you have
which may impact on Do you have a disability?
the way in which a Please state any access needs:
UNISON
representative would
assist you. Please
identify specific needs
(for large print or 5. Member employment details
mobility needs for Job title / occupation: CARE ASSISTANT Payroll no: 09059242
meetings)*
Employment commenced: 11/03/2024 Employment ended: 08/11/2024
This information is
Permanent Temporary Casual Fixed term contract
required if an
Employment Full time Part-time Job share Basic hours per week
Tribunal claim needs
to be made.
Basic wage per week: £ or Basic wage per month: £ 700 - 800
Average take home pay per week: £ Or Basic take home pay per month: £ 700 - 800
Other bonuses or benefits per week: £ or other bonuses or benefits per month: £
Employer head office name: ANCHOR HANDOVER GROUP
Address: 2 GODWIN ST, BRADFORD
Telephone no: 08007312020 Postcode: BD12ST
*This information Workplace name: HALCYON COURT
will also be used to
Address: CLIFFORD RD, WOOD HOUSE, LEEDS
update UNISON’s
member database
Telephone no: 08000854319 Postcode: LS62EZ
Only complete this 6. Fitness to practice
section if you are
Name of registration body: Professional registration PIN number:
seeking representation
in relation to your
professional 7. Disclosure and Barring Service
registration or fitness to Are you barred from working by either the Disclosure and Barring Service or Disclosure Scotland?
practice.
Barred adults list: Yes No Barred children’s list: Yes No
This information will 8. Case details
be used to assist in Date of incident/issue: 08/11/2024
representing you; and
Is the issue ongoing? Yes No
if an Employment Date of dismissal: 08/11/2024
Tribunal claim needs
I am writing to formally addressed recent situation regarding my employment and unexpected
to be made. Please
termination experience.
use a continuation As you recall, i initially expressed my desire to switch roles within the company. At the time, i was informed that this would
only be possible after completing six-months. I successfully passed both first and second reviews, completing fill
sheet if necessary
probationary term.
However, upon reaching my ninth month and formally requesting the agreed-upon role switch, i received an email from
HOME OFFICE stating that company lincense have been revoked which i need to find another switch. The reason cited was
that if the HOME OFFICE were to discover my continued employment, the company would face a fine of 8,000 ponds, an
amount they claimed they could not afford. Shockingly, i was immediately asked to leave the premises during my shift
without prior notice or further discussion.
This sudden termination has left me deeply confused and concerned, especially after fulfilling all the stipulated probationary
requirements. I would appreciate clarification on the following.
1. Why was this issue not identified or addressed during the six-month probationary period?
2. Was there miscommunication or error in documentation that led to this outcome?
3. What steps can be taken to resolve this matter fairly, given that i upheld my end of the agreement
I value the time spent with the company and would like to resolve this matter fairly for both parties
Date(s) of forthcoming hearing(s): DATE Type of hearing:
Date(s) of forthcoming meeting(s): DATE Type of meeting:
9. Please list and attach relevant correspondence (statements/lists of events relating to this
issue/incident)
1. I wasn’t giving termination letter upon dismissal and termination of my job
2. The company never showed me review letter after completing the six month probationary work
3. I have an email from HOME OFFICE confirming the revocation of my company’s lincense
Please state here 10. What would be a solution to your problem?
how you want
i would like to request reinstatement to my role since i passed 6 month probation period and also be
UNISON to help you.
surely given my switch of which agreement was made upon during my early stages of employment.
This information will
be used to assist in Secondly all lost wages since my dismissal must be paid fully to me, i have been unemployed after i was dismissed from my
job
representing you
and/or at an
Employment Tribunal.
This information will 11. Other actions, including other representation and advice
enable us to check a) Has anyone other than UNISON advised or acted on your behalf? Yes No
if you are still If Yes, please give name and organisation of who has advised/acted and give brief details of advice given or actions taken
eligible for
Name:
representation and
Action taken:
advice.
This information will b) Have you or anyone other than UNISON triggered the ACAS Early Conciliation procedure? Yes No
enable UNISON to
pursue an
c) If Yes to (b), when did you trigger the ACAS Early Conciliation procedure? DATE
Employment Tribunal
claim on your behalf.
d) If Yes to (c), have you received an ACAS Early Conciliation certificate? Yes No
e) If Yes to (d), when did you receive the ACAS Early Conciliation certificate? DATE
Please note that if 12. Declarations
your claim goes to
court or an I agree and confirm that:
Employment Tribunal, 11.6 I authorise UNISON to make representations on my
the judgement will be 11.1 I have complied with the Union’s Conditions of Legal behalf to ACAS under the Early Conciliation
made publicly Assistance and will continue to do so.
available. UNISON scheme. When UNISON triggers the ACAS Early
may make public 11.2 my membership subscriptions are up to date and that I Conciliation procedure, and ACAS call me, I will
comments on such inform them that they should speak to the person
will continue paying membership subscriptions until any
judgements
legal claim brought on my behalf comes to an end. from UNISON named in the letter to me from
UNISON, normally my organiser*.
11.3 the information I have provided is a true and
accurate record. 11.7 I have retained a copy for my own future reference.
11.4 any information I provide can be shared with a third party *If ACAS Early Conciliation has been triggered, the
in respect my legal representation in accordance with the branch must contact the organiser for advice on
General Data Protection Regulations 2018 but that no how to proceed. However, please sign the form to
information will be disclosed to any external marketing. avoid delays processing your claim.
11.5 I have not triggered the ACAS Early Conciliation **11.5 and 11.6 do not apply to
procedure, and I understand that it is a condition of my members in Northern Ireland.
representation that I do not trigger the ACAS Early
Conciliation procedure*.
Signature of member: Date: 01/04/2025
Signature of branch official: Date: DATE
(name of branch officer handling the case)
Diversity information 13. Diversity information
will be used to
Do you identify as: x Female Male In another way
monitor whether your
employer’s practices Would you describe yourself as: Lesbian Gay Bisexual
are targeting certain Would you describe yourself as transgender? Yes No Are you disabled? Yes No
groups of people who
What is your race and/or ethnic origin? Black/African
have protected
Are you pregnant or on maternity leave? Yes No
characteristics.
Are you a part time worker? Yes No Are you a fixed time worker? Yes No
Do you think you have been discriminated on the grounds of age and if so, why?
NO
Do you believe you have been discriminated against? Please state on what grounds:
NO
How we use your
information
We don’t routinely transfer your data
At UNISON, we are committed to keeping outside of the UK. However, where it is
your datasecure and to never using it in necessary, we ensure appropriate data UNISON is fully committed to upholding
ways you wouldnot expect. UNISON is protection measures (as applicable under these rights. If you believe we have not
the data controller for theinformation you UK law) are in place. We retain your data done so, please get in touch so that we
provide on this form. We use thisdata to in accordance with UNISON’s data can put things right.
assess if you are eligible for support and retention policy and delete it when it is no For further information on how we will
toprovide this support. longer required.Where you have given use your personal data, you can:
consent for UNISON to process your
We may also use your information to data, you may withdraw it at any time by Go to: unison.org.uk /privacy-policy
pursue ourlegitimate interests as a trade contacting us.
union, such asupdating your details on Email: dataprotection @ unison.co.uk
our database or commentingon You have rights as a data subject. These
Employment Tribunal judgements. We rights include: subject access; erasure; Write to: Data Protection Officer,
may sharethe information on this form rectification; the right to restrict or object UNISON, UNISON Centre, 130 Euston
with our solicitors, anEmployment to processing; the right to data portability; Road, London NW1 2AY
Tribunal, or court. and the right to complain to the
Information Commissioner’s Office (ICO).
FOR THE BRANCH TO FILL IN
1. 1. If this form has come to you because the member has discrimination, unfair dismissal etc), or some within
no workplace representative, please allocate a six months less one day (eg equal pay or redundancy
representative and enter that representative’s name pay). Before a case can be lodged, the ACAS Early
and contact details on the tear-off slip at the back of Conciliation process must be triggered. This process
the form, and return that section to the member without will be triggered by organisers once the Union’s
delay. solicitors advise a case has merit. This is because
triggering the ACAS Early Conciliation process will
2. If you are seeking assistance from the region, please affect the limitation deadline ie the date by which a
ensure that all sections of this form are completed and claim must be lodged. http://www.legislation.gov.uk/
sent to the regional office together with copies of any uksi/2014/254/made.
documents and correspondence which could assist –
an incomplete form is likely to be returned to you,
causing unnecessary delay in the member’s case. 6. If the original time limit for bringing an Employment
Tribunal claim is less than 28 days away, you must
3. You must complete sections 20-21. If there is no contact the organiser/ Case Unit immediately and mark
workplace representative please also complete the form ‘Urgent assistance required’. You must inform
sections 14-16. the member that ACAS pre-conciliation and an
Employment Tribunal claim will only be lodged in
4. If you think this case may involve an application to an
exceptional circumstances.
Employment Tribunal, you must complete section 18
(the section on legal claims) and ensure that the 7. Where a member has already triggered the ACAS Early
member has signed the Declarations in section Conciliation procedure, or lodged a claim prior to
12 before forwarding this Case Form and relevant seeking help from the branch, please contact your
information to the regional office immediately. organiser about next steps, bearing in mind that the
organiser may need to obtain legal advice.
5. Most claims to the Employment Tribunal have to be
lodged within three months less one day of the act, 8. Please sign the form to confirm that all details on the
failure to act or incident (eg form are correct and that the member is up to date with
UNISON subscriptions.
This information will 14. Workplace representative’s details
be used to assist with
Membership no: Position held in branch:
representation; and
Title: First name: Surname:
any Employment
Address:
Tribunal claim made
on behalf of the Postcode:
member. Email: Contact telephone:
15. Employer contact details (the manager you have been dealing with)
Title: First name: Surname:
Address:
Postcode:
Email: Contact telephone:
This information will 16. Branch details
be used to assist with
Branch number/code: Branch name:
representation; and
Service group:
any Employment
Address:
Tribunal claim made
on behalf of the Postcode:
member.
Email: Contact telephone:
17. Details of action taken
If the member’s complaint is a grievance matter, please confirm whether the member’s complaint has been put inwriting to
the employer. If not, please explain the reason for not doing so. Otherwise please enter the date of the letter to the employer
and attach a copy to this form.
Date of letter: DATE
If the member has been disciplined by the employer, please confirm whether the member has lodged an appeal in
writing to the employer. If not, please explain the reason for not doing so. Otherwise please enter the date of the letter
to the employer and attach a copy to this form.
Date of letter: DATE
18. Is there a legal claim?
Yes No
* If Yes, please give the date of the incident and tick one of the options below Date: 16/11/2024
Breach of contract Holiday Pay Unlawful deduction of wages
X Unfair dismissal Redundancy Discrimination** Maternity/pregnancy
TUPE Trade union detriment Protective award
Any other (please state):
** If you have ticked Discrimination, please state the protected characteristic
Age Disability Gender reassignment Maternity/pregnancy
Race Religion or belief Sex Sexual orientation
Please provide as far as possible the exact dates of any incidents (especially discriminatory incidents) that are alleged to
have occured (continue on a separate sheet if necessary)
Date: DATE
Date: DATE
Date: DATE
Date: DATE
Date: DATE
This information will 19. Action taken by branch secretary and regional assistance required
be used to assist with Most claims to the Employment Tribunal have to be lodged within three months less one day of the act, failure to act or
representation; and incident (eg discrimination, unfair dismissal etc), or some cases within 6 months less one day (e.g. equal pay or
any Employment redundancy pay) (“the limitation deadline”).
Tribunal claim made
When was the act, failure to act or incident? DATE When is the limitation deadline? DATE
on behalf of the
member.
A limitation deadline is the date by which a legal claim must be lodged. Have you contacted your region to determine
limitation, especially if you think it might be 28 days or less away? Yes No
Do NOT wait for a grievance or disciplinary process, including any appeal procedure, to conclude. It is important to
contact your organiser straight away in order to meet the limitation deadline*. Inform them IMMEDIATELY BY PHONE if
you think limitation is imminent and legal advice is required.
Please state what action you have taken on behalf of the member, what further action you think is needed; give the dates
of any forthcoming meetings or hearings. Please attach copies of any relevant correspondence.
*For example, If the act was on 1 January 2017, for a claim with a 3-month limitation the deadline to bring a claim is 31 March 2017.
For a claim with a 6-month limitation, the deadline to bring a claim is 30 June 2017.
20. Check list
Has the member completed their sections of the form?
Yes No
If a legal claim has been identified, has this been discussed with the organiser / Case Unit?
Yes No
Have you explained the declaration?
Yes No
Have you explained that if the member’s case has reasonable prospects of success:
1. UNISON’s organisers from the region will trigger the Early Conciliation procedure;
2. That ACAS must be notified about the dispute through their Early Conciliation service before an ET
claim can be lodged;
3. Sought authority from the member for their organiser to speak on the member’s behalf to ACAS;
4. Explained and agreed with the member that when ACAS calls, the member will ask ACAS to speak
instead to their organiser or the person named in the letter confirming representation to the member.
Yes No
Are the following documents attached?
Contract of employment Dismissal letter Appeal letter
Grievance letter Disciplinary procedure Redeployment procedure
Grievance procedure Sickness absence Disability discrimination policy
ACAS Early Conciliation Certificate (if relevant)
Any other (please give details):
Incomplete information will lead to delays and may mean the member loses the opportunity to lodge an Employment
Tribunal claim. Always be aware of deadlines to bring a case to the employment tribunal.
21. Branch secretary authorisation
Name:
Signature of branch secretary: Date: DATE
Please use this space for any extra information.
