Completed by

Date completed

Learner Name

Date of Birth


Date of last contact (training, review, observation)
Reason for withdrwal

Full details of reason for withdrawal

Details of support given to learner

Is there a vacancy at the dealership

Details of what has been done to retain the learner

Is the learner seeking a placement at another dealership

Assessor/Reviewer signature
Manager signature

Details why there is no Manager signature

Please note that this checklist is a hypothetical example and provides basic information only. It is not intended to take the place of, among other things, workplace, health and safety advice; medical advice, diagnosis, or treatment; or other applicable laws. You should also seek your own professional advice to determine if the use of such checklist is permissible in your workplace or jurisdiction.