PORTFOLIO OF EVIDENCE

UNIT STANDARD

9012, 9013 & 7456.

National Certificate: Hygiene and Cleaning Supervision

SAQA ID: 20175 Level 3
Credits 120

Mathematical Literacy
Module 5
Portfolio of Evidence

Name

Contact Address

Telephone (H)

Telephone (W)

Facsimile

Cellular
Learner Information:
Details Please Complete this Section
Name & Surname:
Organisation:
Unit/Dept.:
Facilitator Name:
Date Started:
Date of Completion:

Copyright
All rights reserved. The copyright of this document, its previous editions and any annexures thereto, is
protected and expressly reserved. No part of this document may be reproduced, stored in a retrievable
system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording or
otherwise without the prior permission.

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 OVERVIEW

About the Learner This Learner Exercise Workbook has been designed and developed to evaluate
Workbook learners’ level of understanding of the
-Demonstrate an understanding of the use of different number bases and
measurement units and an awareness of error in the context of relevant
calculations.
-Describe, apply, analyse and calculate shape and motion in 2-and 3-
dimensional space in different contexts
- Use mathematics to investigate and monitor the financial aspects of
personal, business and national issues module.
It forms part of a series of Learner Workbooks that have been developed for
National Certificate: Hygiene and Cleaning Supervision, ID 20175 LEVEL 3 –
CREDITS 120
Purpose The purpose of this Learner Exercise Workbook is to evaluate learners
understanding on the specific outcomes and/or assessment criteria of the
following SAQA Registered Unit Standards:
US No US Title Level Credits
9012 Investigate life and work related problems using data 3 5
and probabilities
9013 Describe, apply, analyse and calculate shape and motion 3 4
in 2-and 3-dimensional space in different contexts

7456 Use mathematics to investigate and monitor the 3 5

financial aspects of personal, business and national
issues

Context This assessment represents the Formative Assessment component of the

- Investigate life and work related problems using data and probabilities.
-Describe, apply, analyse and calculate shape and motion in 2-and 3-
dimensional space in different contexts
- Use mathematics to investigate and monitor the financial aspects of
personal, business and national issues module, for the NATIONAL

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 CERTIFICATE: BOOKKEEPING ID 58375 LEVEL 3 – CREDITS 12. And should be
completed in the classroom/training room.
Resources The following are resources needed for this assessment:
1. Learner Guide; and
2. Assessment Preparation.
Instructions to Facilitators will be required to:
Facilitators  Explain the completion of the workbook to each learner; and
 Interview the learner on similar questions, should he/she not be able
to write.
Instructions to Learners will be required to:
Learners  Complete the workbook as per the instructions;
 Ensure that all questions are completed;
 Ensure that the completion of the workbook is their own work;
 Ensure that all annexure are attached to the workbook and clearly
referred to;
Assessment Time Learners are required to complete this assessment within the allocated time
frame of.... hours.
Total Mark This formative assessment carries a total mark of _ points. In order to meet the
pass mark, learners are required to achieve a minimum of 80% of the total
marks.
Equipment Learners are required to have the following equipment in order to complete
this workbook:
 Pen and Pencil;
 Ruler; and
 Exam Pad – for additional paper.

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 ASSESSMENT PREPARATION CHECKLIST
DESCRIPTION YES NO COMMENTS/CONTINGENCY
This assessment is a formative assessment and it is based on the
outlined unit standard/s for the
 Investigate life and work related problems using data and
probabilities
Your assessment evidence for the
 Investigate life and work related problems using data and
probabilities module needs to be submitted on....... (day)

of...............(month)...........(year) at the following

address/place................................................................
You will be assessed based on the outlined Unit Standards. The
assessment activities are linked to specific outcomes/assessment
criteria of the outlined Unit Standards.
To determine your competence level, the following are the methods
to be used for this assessment:
1. .....................................................
2. .....................................................
To be declared competent on the
 Investigate life and work related problems using data and
probabilities module (formative assessment), you should have
obtained at least 80% of the total mark of this assessment.
You will be provided with detailed feedback on your performance of
this assessment as follows:
1. Written Feedback
2. Verbal Feedback
Should you be declared “not yet competent” on this assessment, you
will be entitled for re-assessment opportunity/ies.
You will be required to re-submit evidence (only for areas) you were
declared not yet competent. A date for re-submission will be agreed
with the assessor.
You will be entitled to lodge an appeal should you not be satisfied
with the assessment decision of your assessment.
You will be required to provide the assessor feedback on assessment
procedure – this is to assist in improving the assessment practices.
Your results of assessment and portfolio of evidence information will
not be provided to any person without your written consent.

Learner’s Declaration

I…………………………………………………………………………………………….herewith declare that I am ready for the

assessment, that we have reviewed the assessment preparation and plan, I understand the assessment process
and I am happy that the assessment will be conducted in a fair manner.
Learner Signature: Date: Facilitator Signature: Date:

Formative Assessments 9012

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 ACTIVITY 1
Consider the following table from Stats SA.

What does column 2 represent?

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What does column 5 represent?

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Which column represents the number of males living in non-urban areas?

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If you wanted to find the total number of people, 16 years and older, living in a certain province, which
column would you look in?

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How many males, 16 years and older, live in urban areas in Kwa-Zulu-Natal?

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Assessor Feedback:

ACTIVITY 2
Every year millions of man days are lost because of people striking. A man day is one work day for one
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 person. In other words, if 20 people strike for one day, 20 man days are lost. If 20 people strike for 2
days, 40 man days are lost. Look at this table of man days lost because of strikes:

Draw a bar graph to represent the data in the table. Label the axes of your graph.

Use the space below to draw your bar graph.

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 ACTIVITY 3
The Human Resources Manager of a company employing 200 workers conducts a survey to
investigate whether there is a relationship between the age of workers and the number of days they
are absent per year. He takes a sample of 15 files and records the age and the number of days absent
of the workers in the sample. He then plots the results of the survey on the following scatter graph:

 Use your ruler to draw a line of best fit.

 Do you think the department would decide that there is a correlation between the number of
days absent and the age of workers? If yes, describe the correlation (positive or negative?) and
explain.
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  Using your line of best fit, estimate:

i) How many days a 35 year old worker can be expected to be absent in a year.

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ii) The age of a worker who is likely to be absent for 3 days in a year.

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Assessor Feedback:

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Summative Assessments 9012

ACTIVITY 1
Three sets of data are given:

1. Data Set 1: 8 11 11 13 15 21 23

2. Data Set 2: 6 6 7 10 12 14 15 15

3. Data Set 3: 10 14 15 16 18 18 21 23 26

For each set of data find:

a) The mode

b) The median

c) The mean (correct to one decimal place)

d) The range

e) The lower quartile

f) The upper quartile

g) The interquartile range

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 ACTIVITY 2
In a pack of cards, there are 52 cards. There are 4 suits: diamonds, hearts, spades and clubs. Each suit
has a King, a Queen, a Jack and an Ace. It also has cards for 2, 3, 4, 5,

6, 7, 8, 9 and 10. If the pack has been shuffled so that the cards are in no particular order,

and you select one card from the pack without looking, what is the probability of selecting:

a) a Queen

b) a red Queen

c) a Jack of Hearts

d) a Jack of Hearts or Diamonds

e) any club

f) a six or a seven

g) a black six

h) a picture card (Jack, Queen or King)

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 ACTIVITY 3
A soccer team has two different coloured shorts and two different coloured shirts for their kit.

Complete the tree diagram below and then use it to fill in the table:

♦ How many combinations are there?

♦ Calculate (in ratio form) the probability that the soccer team wear:

i) black shorts and white shirt

ii) blue shorts and yellow shirt

iii) green shorts

iv) yellow shirts

v) black shorts

vi) black shorts or white shirts

vii) blue shorts or yellow shirts

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ACTIVITY 4
A Maths facilitator wanted to see whether there was a correlation between the numbers of hours
that learners spent studying and the marks achieved for their summative assessments.

She gathered the following information from 12 learners in her NQF 3 Maths Class

♦ Draw a scatter graph showing the information from the table.

Use the space below to draw your scatter graph.

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  Is there a correlation between the numbers of hours that learners spent studying and the marks
achieved for their summative assessments? If yes, describe it.
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 Use your ruler to draw a line of best fit.

 Use your line of best fit to predict:

i) How long a learner who achieves 55% studied for?

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ii) What assessment mark someone who studies for 2½ hours can expect.
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Assessor Feedback:
 Summative Assessments – Reflexive Assignment
Unit Standard: 9012
Investigate life and work related problems using data and probabilities.

Instructions:

Please answer the following questions to demonstrate how you have grown professionally from learning
and assessment. Please do not provide us with one line sentences. The answers to these questions are
testing your reflexive competence.

1. What new skills did you learn?

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2. Which skills did you implement in the workplace?

_____________________________________________________________________________________
_____________________________________________________________________________________

3. What positive changes did new skills bring to your department?

_____________________________________________________________________________________
_____________________________________________________________________________________

4. Which skills [if any] did not work for you? Why do you think they did not work?

_____________________________________________________________________________________
_____________________________________________________________________________________

5. What changes do you plan to implement in future?

_____________________________________________________________________________________
_____________________________________________________________________________________

6. Did the training and assessment make an impact on your personal development? Explain the impact.

_____________________________________________________________________________________
_____________________________________________________________________________________

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 Log Book
Unit Standard: 9012
Investigate life and work related problems using data and probabilities.
Instructions:
Complete this individually. This logbook has been included to record all the time spent on the
assessment and other activities related to this skills programme. NOTE: Your total hours spent on all
activities including classroom training, practical assignments, PoE compiling, self-study, etc., should
equal 10 hours for each credit.

Date Formative Assessments Hours Spent On Activity

Date Summative Assessments Hours Spent On Activity

Date Practical Assessments Hours Spent On Activity

Date Reflexive Assessments Hours Spent On Activity

Verified by: ___________________ Signature: ______________ Position: ___________________

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 NATIONAL CERTIFICATE: HYGIENE AND CLEANING
SUPERVISION
ID 20175
LEVEL 3 – CREDITS 120
LEARNER WORKBOOK
SAQA: 9013
DESCRIBE, APPLY, ANALYSE AND CALCULATE SHAPE AND
MOTION IN 2-AND 3-DIMENSIONAL SPACE IN DIFFERENT
CONTEXTS

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ASSESSMENT PREPARATION CHECKLIST
DESCRIPTION YES NO COMMENTS/CONTINGENCY

This assessment is a formative assessment and it is based on

the outlined unit standard/s for the DESCRIBE, APPLY,
ANALYSE AND CALCULATE SHAPE AND MOTION IN 2-AND 3-
DIMENSIONAL SPACE IN DIFFERENT CONTEXTS module.

Your assessment evidence for the DESCRIBE, APPLY, ANALYSE

AND CALCULATE SHAPE AND MOTION IN 2-AND 3-
DIMENSIONAL SPACE IN DIFFERENT CONTEXTS module needs
to be submitted on....... (day) of...............(month)...........(year)
at the following
address/place................................................................

You will be assessed based on the outlined Unit Standards. The

assessment activities are linked to specific
outcomes/assessment criteria of the outlined Unit Standards.

To determine your competence level, the following are the

methods to be used for this assessment:

iii) .....................................................

iv) .....................................................

To be declared competent on the DESCRIBE, APPLY, ANALYSE

AND CALCULATE SHAPE AND MOTION IN 2-AND 3-
DIMENSIONAL SPACE IN DIFFERENT CONTEXTS module
(formative assessment), you should have obtained at least 80%
of the total mark of this assessment.

You will be provided with detailed feedback on your

performance of this assessment as follows:

3. Written Feedback

4. Verbal Feedback

Should you be declared “not yet competent” on this

assessment, you will be entitled for re-assessment

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 opportunity/ies.

You will be required to re-submit evidence (only for areas) you

were declared not yet competent. A date for re-submission will
be agreed with the assessor.

You will be entitled to lodge an appeal should you not be

satisfied with the assessment decision of your assessment.

You will be required to provide the assessor feedback on

assessment procedure – this is to assist in improving the
assessment practices.

Your results of assessment and portfolio of evidence

information will not be provided to any person without your
written consent.

Learner’s Declaration

I…………………………………………………………………………………………….herewith declare that I am ready for the

assessment, that we have reviewed the assessment preparation and plan, I understand the assessment
process and I am happy that the assessment will be conducted in a fair manner.

Learner Signature: Date: Facilitator Signature: Date:

Formative Assessments 9013

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 ACTIVITY 1
Convert the following using the metric system:

a) 35 m = _______________ mm

b) 0,7 m = _______________ cm

c) 56 mm = _______________ m

d) 80 km = _______________ m

e) 32 cm = _______________ mm

f) 790 cm = _______________ m

g) 38 543 g = _______________ kg

h) 789 mg = _______________ g

i) 2,5 l = _______________ ml

j) 90 ml = _______________ l

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ACTIVITY 2
Use the theorem of Pythagoras to calculate the following:

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 ♦ A rectangular field is to be divided along its diagonal PR into two plots. If the

dimensions of the field are 150m × 75m calculate the length of the fencing needed

to divide the field (length of PR)

♦ Round off to an acceptable level of accuracy.

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ACTIVITY 3
Calculate the length of side GH in ΔFGH.
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ACTIVITY 4
Find the length of side CD in ΔCDE.

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 ACTIVITY 5
A cylindrical can has a height of 12 cm and a diameter of 6 cm. Find:

i) its volume

ii) its surface area (draw a net of it first)

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Assessor Feedback:

Summative Assessments 9013

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 ACTIVITY 1
♦ On a plan the dimensions of a room are 35 mm × 45 mm. Give the actual dimensions of the room
if the scale of the drawing is:

i) 1 : 1000
ii) 1 : 200
iii) 1 : 150
iv) 1 : 800

♦ Using a scale of 1 : 250, draw an accurate plan of a rectangular garden measuring 25 m × 15 m.

Draw in a rectangular shed measuring 5 m × 4 m

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ACTIVITY 2
♦ If a man runs 5 km in 30 minutes, at what speed is he running?

♦ Draw a set of axes and plot the following points:

⇒ H (1;2) , I (4;0) , J (3;-4) , K (-1;6) , L (-4;5) , M (0;3) , N (2;-2)

(Remember! The x -axis is written first, then the y -axis)

Use a blank page to draw your set of axes.

ACTIVITY 3
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 Use the formulae of perimeter, area, volume and surface area to calculate the following:

♦ Find the volume of a box with a rectangular base measuring 20 cm by 5 cm and a height of 25 cm.
(Draw a rough sketch of the box).

ii) How many of these boxes can be packed into a crate measuring 50 cm by 35 cm by 40 cm?

iii) Find the surface area of the box (draw a net of it first).

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Assessor Feedback:

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 Summative Assessments – Reflexive Assignment
Unit Standard: 9013
Describe, apply, analyse and calculate shape and motion in 2-and 3-dimensional space in
different contexts.
Instructions:

Please answer the following questions to demonstrate how you have grown professionally from learning
and assessment. Please do not provide us with one line sentences. The answers to these questions are
testing your reflexive competence.

1. What new skills did you learn?

_____________________________________________________________________________________
_____________________________________________________________________________________

2. Which skills did you implement in the workplace?

_____________________________________________________________________________________
_____________________________________________________________________________________

3. What positive changes did new skills bring to your department?

_____________________________________________________________________________________
_____________________________________________________________________________________

4. Which skills [if any] did not work for you? Why do you think they did not work?

_____________________________________________________________________________________
_____________________________________________________________________________________

5. What changes do you plan to implement in future?

_____________________________________________________________________________________
_____________________________________________________________________________________

6. Did the training and assessment make an impact on your personal development? Explain the impact.

_____________________________________________________________________________________
_____________________________________________________________________________________

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 Log Book
Unit Standard: 9013
Describe, apply, analyse and calculate shape and motion in 2-and 3-dimensional space in
different contexts.

Instructions:
Complete this individually. This logbook has been included to record all the time spent on the
assessment and other activities related to this skills programme. NOTE: Your total hours spent on all
activities including classroom training, practical assignments, PoE compiling, self-study, etc., should
equal 10 hours for each credit.

Date Formative Assessments Hours Spent On Activity

Date Summative Assessments Hours Spent On Activity

Date Practical Assessments Hours Spent On Activity

Date Reflexive Assessments Hours Spent On Activity

Verified by: ___________________ Signature: ______________ Position: ___________________

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 National Certificate: Hygiene and Cleaning Supervision
ID 20175 LEVEL 3 – CREDITS 120
US ID: 7456
LEARNER WORKBOOK
Use mathematics to investigate and monitor the financial
aspects of personal, business and national issues

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 ASSESSMENT PREPARATION CHECKLIST
DESCRIPTION YES NO COMMENTS/CONTINGENCY

This assessment is a formative assessment and it is based on

the outlined unit standard/s for the Use mathematics to
investigate and monitor the financial aspects of personal,
business and national issues module.

Your assessment evidence for the Use mathematics to

investigate and monitor the financial aspects of personal,
business and national issues module needs to be submitted
on....... (day) of...............(month)...........(year) at the following
address/place................................................................

You will be assessed based on the outlined Unit Standards. The

assessment activities are linked to specific
outcomes/assessment criteria of the outlined Unit Standards.

To determine your competence level, the following are the

methods to be used for this assessment:

v) .....................................................

vi) .....................................................

To be declared competent on the Use mathematics to

investigate and monitor the financial aspects of personal,
business and national issues module (formative assessment),
you should have obtained at least 80% of the total mark of this
assessment.

You will be provided with detailed feedback on your

performance of this assessment as follows:

5. Written Feedback

6. Verbal Feedback

Should you be declared “not yet competent” on this

assessment, you will be entitled for re-assessment
opportunity/ies.

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 You will be required to re-submit evidence (only for areas) you
were declared not yet competent. A date for re-submission will
be agreed with the assessor.

You will be entitled to lodge an appeal should you not be

satisfied with the assessment decision of your assessment.

You will be required to provide the assessor feedback on

assessment procedure – this is to assist in improving the
assessment practices.

Your results of assessment and portfolio of evidence

information will not be provided to any person without your
written consent.

Learner’s Declaration

I…………………………………………………………………………………………….herewith declare that I am ready for the

assessment, that we have reviewed the assessment preparation and plan, I understand the assessment
process and I am happy that the assessment will be conducted in a fair manner.

Learner Signature: Date: Facilitator Signature: Date:

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 Formative Assessments 7456
ACTIVITY 1

You have a monthly income of R5 500.00. Draw up a realistic monthly budget that you should be
able to follow for at least eight months. The following fixed monthly expenses

must appear on your budget:

♦ Rent - R1 500.00

♦ Electricity - R 185.00

♦ Transport - R 450.00

♦ Cell phone - R 375.00

♦ Medical aid - R 500.00

♦ Savings - R 400.00

Please use an A4 blank page to answer the question

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 ACTIVITY 2

Tom celebrated his 21st birthday in January 2008. His parents invested R10 000 in January 1997 at
9.5% p.a. interest compounded annually. They planned to use the money to buy him a car for a
birthday present.

♦ How much money will they receive from this investment on his 21st birthday?

♦ How much of this money is interest?

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ACTIVITY 3

Palesa considers two investment options.

♦ Bank A offers 7% p.a. compound interest if she invests R15 000 for five years.

♦ Bank B offers 8, 5% p.a. simple interest if she invests R15 000 for five years.

i) Which of these two investments earns her more interest?

ii) How much more does she earn on the better investment?

iii) Is compound interest always the better option? Explain your answer.

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 Summative Assessments 7456
ACTIVITY 1
A course at university costs R10 000 rand. If a father wishes to send his daughter to do this in five
years’ time, what will it cost him if the rate of inflation is estimated to be 11,5% p.a.?

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ACTIVITY 2
Bheki's house is valued at R200 000. If houses in his neighbourhood are appreciating at a rate of
12% p.a., what can he expect to sell his house for after two years?

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ACTIVITY 3
A company's machinery is valued at R950 000. If it depreciates at 5% p.a. what will it be worth after
three years?

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Assessor Feedback:

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 Summative Assessments – Reflexive Assignment
Unit Standard: 7456
Use mathematics to investigate and monitor the financial aspects of personal, business and
national issues.

Instructions:

Please answer the following questions to demonstrate how you have grown professionally from learning
and assessment. Please do not provide us with one line sentences. The answers to these questions are
testing your reflexive competence.

1. What new skills did you learn?

_____________________________________________________________________________________
_____________________________________________________________________________________

2. Which skills did you implement in the workplace?

_____________________________________________________________________________________
_____________________________________________________________________________________

3. What positive changes did new skills bring to your department?

_____________________________________________________________________________________
_____________________________________________________________________________________

4. Which skills [if any] did not work for you? Why do you think they did not work?

_____________________________________________________________________________________
_____________________________________________________________________________________

5. What changes do you plan to implement in future?

_____________________________________________________________________________________
_____________________________________________________________________________________

6. Did the training and assessment make an impact on your personal development? Explain the impact.

_____________________________________________________________________________________
_____________________________________________________________________________________

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 Log Book
Unit Standard: 7456
Use mathematics to investigate and monitor the financial aspects of personal, business and
national issues.

Instructions:
Complete this individually. This logbook has been included to record all the time spent on the
assessment and other activities related to this skills programme. NOTE: Your total hours spent on all
activities including classroom training, practical assignments, PoE compiling, self-study, etc., should
equal 10 hours for each credit.

Date Formative Assessments Hours Spent On Activity

Date Summative Assessments Hours Spent On Activity

Date Practical Assessments Hours Spent On Activity

Date Reflexive Assessments Hours Spent On Activity

Verified by: ___________________ Signature: ______________ Position: ___________________

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 Testimonial- Supervisor/ Manager

Unit Standard 9012, 9013 & 7456.

I hereby declare that the learner (name), _____________________________________

ID number ______________________________________

presented the report / performed the work documented in this POE, as per assessment criteria and
specific outcomes and overall requirements of the unit standards(9012, 9013 & 7456) in my presence on
(dates)

_______________________________________________________________

This evidence (of performance) include the following:

Manager Name: Signature:

Title/Position: Date:

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Candidate Signature Date

 Assessment Review Report
NAME of LEARNER: NAME of ASSESSOR:
VENUE : DATE of REVIEW:
US No US Title Level Credit

LEARNER/
Review Dimension ASSESSOR ACTION
CANDIDATE

The principles/criteria for good assessment Agree Agree

were achieved? Disagree Disagree

The assessment related to the registered Agree Agree

unit standard? Disagree Disagree

Agree Agree
The assessment was practical?
Disagree Disagree
It was time efficient and cost-effective and
Agree Agree
did not interfere with my normal
Disagree Disagree
responsibilities?
The assessment instruments was fair, clear Agree Agree
and understandable Disagree Disagree

The assessment judgement was made Agree Agree

against set requirements Disagree Disagree

Agree Agree
The venue and equipment was functional?
Disagree Disagree
Special needs were identified and the Agree Agree
assessment plan was adjusted Disagree Disagree
Feedback was constructive against the Agree Agree
evidence required Disagree Disagree

Agree Agree
An opportunity to appeals was given
Disagree Disagree

Agree Agree
The evidence was recorded
Disagree Disagree

Learner’s declaration of understanding

I am aware of the moderation process and understand that the moderator could declare the assessment decision invalid.

Learner Signature Assessor Signature Moderator Signature

Date: Date: Date:

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Candidate Signature Date

 Appeals Procedure
Familiarise yourself with the appeals procedure and sign the document as requested. You will only use the Appeals
Form if you would like to appeal against the assessment decision.
The Training Provider acknowledges a Learner’s right to appeal against or dispute any assessment decision.
You can appeal under the following circumstances:
 I do not agree with my assessment decision – I feel I have provided sufficient evidence
 I was not briefed properly of the nature and requirements of assessment
 I was unfairly discriminated against
 My special needs for this assessment were not accommodated

If you would like to appeal, please follow the procedure below:

Stage 1:
 Approach the workshop organiser to state your case for re-assessment within 14 working days of being
informed of the assessment decision. Complete and submit the appeals form within the 14 days.
 The Training Provider will respond to all appeals and disputes received within 14 working days.
 The workshop organiser will consider the appeal and forward to the assessor if required.
 The assessor will respond with either:
 A clear explanation stating why the assessment decision is upheld combined with a re-evaluation of
the evidence.
 An amendment of the Learner’s Assessment Record, should this be appropriate.

Stage 2:
 Should the decision made by the assessor be unsatisfactory, the appeal will be forwarded to the
moderator for mediation and possible re-assessment.

Stage 3:
 The Training Provider management would be approached as the next step, should the decision not be
accepted. A panel will be selected to administer the appeal.
 The Learner is invited to attend the proceedings held by the panel.

Stage 4:
 Once all internal appeals and dispute systems have been exhausted, appeals and disputes can be referred
to the relevant ETQA for investigation.

Declaration: I hereby confirm that the above procedures have been explained to me and I accept them.

Learner Name: Signature: Date: ____.

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Candidate Signature Date

 Appeals Form
CONDITION/S UNDER WHICH I AM SELECTING TO MAKE THIS APPEAL (select one)

 I do not agree with my assessment decision – I feel I have provided sufficient evidence
 I was not briefed properly of the nature and requirements of assessment
 I was unfairly discriminated against
 My special needs for this assessment were not accommodated

I hereby appeal against the assessment decision:

(name & surname)

Training Provider
Programme
Unit Standard(s)
Assessor Assessment Date

Reason for appeal

Learner Signature Date of Appeal

Stage 1: Assessor Response
Decision Amended Decision Upheld
Assessor’s rationale for
decision

Assessor Signature Date of Response

The above decision have been explained to me and I accept the decision YES NO
Learner Signature Date
Stage 2: Moderator Response
Decision Amended Decision Upheld
Moderator’s rationale
for decision
Moderator Name Date of Response
Moderator Signature
The above decision have been explained to me and I accept the decision YES NO
Learner Signature Date
Stage 3: Management Response
Decision Amended Decision Upheld
Rationale for decision

Panel Date of Response

Name Signature
Name Signature
Name Signature
The above decision have been explained to me and I accept the decision YES NO
Learner Signature Date
Stage 4: ETQA The appeal has been referred for investigation YES NO

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Candidate Signature Date