Fillable Esa-50-capability-for-work-questionnaire ESA50 - capability for work questionnaire

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Esa-50-capability-for-work-questionnaire ESA50 - capability for work questionnaire

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Please contact the DWP Online helpdesk.
Phone: 0800
169
0154
Email: dwponline.helpdesk@dwp.gsi.gov.uk
Opening hours
Monday to Friday: 8am - 6pm
Closed on weekends and all Public and Bank Holidays.
For help and advice on the information you need to put on the form or
about the benefit you want to claim, contact the office that deals with the
benefit.
Calls to 0800 numbers are free from landlines or mobiles.
Capability for Work questionnaire
If you would like this questionnaire in Braille, large print or audio, please
call Jobcentre Plus on 0800 169 0310 or textphone 0800 169 0314 and
tell us which you need.
If you live in Wales and want this questionnaire in Welsh please call us on
0800 328 1744.
Calls to 0800 numbers are free from landlines and mobiles.
What you need to do
l Please fill in this questionnaire and send it back to the Health
Assessment Advisory Service by the date on the letter that it came with.
The Health Assessment Advisory Service will use the information you
provide to decide if you need to come for a face-to-face assessment or
not. We will use this information to give you the best support we can and
pay you the right amount of benefit.
l You must send it back by the date we’ve asked you to in the
enclosedletter.
l Read this questionnaire carefully and make sure you answer all the
questions in full.
l Write in black ink and use CAPITALLETTERS. If you want to, you can
download a copy of the questionnaire to your computer and fill it in.
Goto www.gov.uk and search for ESA50.
l Return the completed questionnaire using the enclosed envelope.
Itdoesn’t need a stamp. Do not send it or take this to your
JobcentrePlus office.
Send copies of all your medical or other information back with your
questionnaire. We don’t always contact your medical professionals so this
information is important, and should let us know how your disability,
illness or health condition affect how you can do things on a daily basis.
Alist of information we find helpful is on page 5.
l Only send us copies of medical or other information if you already have
them. Don’t ask or pay for new information or send us original
documents. Please write your national insurance number on each piece
of information you send to us.
l Make sure you fill in the '
About you' section on page 2 in full.
If you need help filling in the questionnaire, you can
l ask a friend, relative, carer or support worker to helpyou
l call Jobcentre Plus on 0800 169 0310 to arrange for a trained advisor to
talk you through the questions over the phone. Please do not go into
your local Jobcentre Plus
In some cases, your answers can be written down for you. You can ask for
your questionnaire to be sent to you by post to check.
Your Employment and Support Allowance (ESA) payments
may stop if you don’t fill in this questionnaire and send it
to the Health Assessment Advisory Service by the date we
have asked you to.
ESA50 05/18
2
Other title
Surname
Other names
Title
Address
Postcode
Date of birth
National Insurance (NI) number
A phone number we can contact
you on
Email address, if you have one.
Have you been in hospital for over
28 days in the last 12 months?
Please tell us the dates you were
in hospital.
What was the name of the
hospital.
Have you served in HM Forces?
Which service were you in?
What date did you leave?
Have you been released from
prison in the last 6 months?
What date did you leave?
This information will help us
find your medical records more
quickly. We will not share or
use this information for any
other purpose.
Are you pregnant?
Letters
Numbers
Letter
About you
No
Yes
When is your baby due?
Please fill in this f
orm with BLACK INK and in CAPITALS.
No
Yes
From To
No
Yes
Army
Go to the next question.
Royal Navy/Marines
RAF
Go to the next question.
No
Yes
Go to the next question.
ESA50 05/18
Please tell us why:
If you are returning this questionnaire late
Your Employment and Support Allowance (ESA) payments may stop if you do not fill in this
questionnaire and send it to the Health Assessment Advisory Service. It is important that you
send it back by the date we have asked you to in the enclosed letter.
Are you sending this questionnaire
No
back later than the date we asked
Yes
you to in the enclosed letter?
3
ESA50 05/18
About your General Practitioner (GP) or doctor’s surgery
Please tell us about your GP. If you don’t know your GP’s name, tell us the name of your doctor’s
surgery. Sometimes we will need to contact them to ask for medical or other information that tells us
how your disability, illness or health condition affect your ability to do things on a daily basis. We don’t
always have to contact them, so it’s important that you send all of your medical or other information
back with this questionnaire. Only send us copies of medical or other information if you already
have them. Don’task or pay for new information or send us original documents. Please write your
national
insurance number on each piece of information you send to us.
What is your GP’s name or the
name of your doctor’s surgery?
Their address
Postcode
Their phone number
Their name
Their Job title
Their address
Postcode
Their phone number
About other Healthcare Professionals, carers, friends or relatives who
know the most about your disability, illness or health condition
Please give us details of the Healthcare Professionals, carers, friends or relatives who know the most
about your disability, illness or health condition. They should know what effect your
disability, illness or health condition has on your ability to do things on a daily basis. We don’t always
contact them, so it’s important you send all of your medical or other information back
with this questionnaire. Only send us copies of medical or other information if you already
have them. Don’t ask or pay for new information or send us original documents. Please write your
national insurance number on each piece of information you send to us.
For example:
l consultant or specialist doctor
l psychiatrist
l specialist nurse, such as Community Psychiatric Nurse
l physiotherapist
l occupational therapist
l social worker
l support worker or personal assistant
l carer
4
ESA50 05/18
About medical or other information you may already have
Things the Health Assessment Advisory Service don’t need to see –
General information about your medical conditions l Internet printouts.
that are not about you personally. Such as: l Statement of Fitness for Work, otherwise
l
Photographs. known as fit notes, medical certificates,
l Letters about other benefits. doctor’s statements or sick notes.
l Fact sheets about your medication l Appointment letters
3
5
Things the Health Assessment Advisory Service would like to see, if you already have them –
Reports, care or treatment plans about you from: Medical test results including:
l GPs l scans
l hospital doctors l audiology
l specialist nurses l the results of x-rays, but not the x-rays
l community psychiatric nurses themselves
l occupational therapists
l physiotherapists
Things like:
l social workers
l your current prescription list
l support workers
l your statement of special educational needs
l learning disability support teams
l epilepsy seizure diary
l counsellors or carers
l your certificate of visual impairment
Other information:
l Hospital Passports This is a written record kept by people with learning disabilities to provide hospital
staff with important information about them and their health when they are admitted to hospital.
l Education Health Plans.
l A diary of your symptoms if your disability, illness or health condition varies from day to day.
l Long-stay hospital information including date of admission, length of stay and the hospital name
and address.
Remember – only send us copies of medical or other information if you already have them. Don’t ask
or pay for new information or send us original documents. Please write your national insurance number
on each piece of information you send to us.
Cancer treatment
IMPORTANT: If your cancer treatment is affecting you and you have no other health
conditions, you do not have to answer all the questions on this questionnaire
Do you have cancer?
No
Yes
Are you having, waiting for or
No
recovering from chemotherapy or
radiotherapy treatment for cancer?
Yes
Do you have other health problems,
No
as well as cancer and the problems
resulting from your cancer
treatment?
Yes
Go to About your disabilities, illnesses or health
conditions on
page 6.
Please go to the next question.
Go to About your disabilities, illnesses or health
conditions on
page 6.
Please make sure page 24 is filled in and signed by your
Healthcare Professional. This may include a GP, hospital doctor
or clinical nurse who is aware of your cancer treatment.
When your Healthcare Professional has signed page 24 and
you have signed page 22 you can then return this
questionnaire using the enclosed envelope.
Please make sure page 24 has been filled in and signed by
your Healthcare Professional and you’ve signed page 22.
You can then return this questionnaire using the enclosed
envelope.
Please fill in the rest of this questionnaire.
5
ESA50 05/18
About your disabilities, illnesses or health conditions
We will ask you specific questions about how your disability, illness or health condition affect
your ability to do things on a daily basis in the rest of this questionnaire.
Please tell us
l what your disabilities. illnesses
or health conditions are
l how they affect you
l when they started
l if you think any of your
conditions are linked to drugs or
alcohol
Please tell us about
l any aids you use, such as a
wheelchair or hearing aid
l anything else you think we
should know about your
disabilities, illnesses or health
conditions
If you need more space, please use
page 21 or a separate sheet
of paper.
6
ESA50 05/18
Hospital, clinic or special treatment like dialysis or rehabilitation treatment
Use this section to tell us about any:
l hospital or clinic treatment you are having
l hospital or clinic treatment you expect to have in the near future
l special treatment you are having such as dialysis or rehabilitation treatment
Please also tell us about any special treatment you have which you may not go to a hospital or clinic for.
No
Yes
No
Yes
Tell us about all your hospital,
clinic or special tr
eatment.
For example
l what treatment you are having
l where you go to get the treatment
l how often you go for the
treatment
If you are expecting to have
treatment in the near future, tell us
l what the treatment will be
l the date it’s due to start
If you need more space, use the
space on page 21 or a separate
sheet of paper.
Are you having or waiting for any
treatment which needs you to stay
somewhere overnight or longer?
If you need more space, use the
space on page 21 or a separate
sheet of paper.
Are you in, or due to start
aresidential rehabilitation
scheme?
If you need more space, use the
space on page 21 or a separate
sheet of paper.
Go to Part 1 on the next page.
Tell us about this below.
Go to Part 1 on the next page.
Tell us the name of the organisation running your
scheme, when your treatment began, or is due to begin,
and when you expect it to end.
About your disabilities, illnesses or health conditions continued
Please tell us about any tablets,
liquids, inhalers or other medication
you are taking and any side effects
you have.
You can find a list of your
medications on your latest
prescription.
If you need more space, please use
page 21 or a separate sheet
of paper.
7
ESA50 05/18
Only answer Yes to the following questions, if you can do the activity safely, to an acceptable standard,
asoften as you need to and in a reasonable length of time.
1. Moving around and using steps
By moving we mean including the use of aids you usually use such as a manual wheelchair, crutches or a
walking stick but without the help of another person.
Please tick this box if you can
move around and use steps
without difficulty.
How far can you move safely and
repeatedly on level ground without
needing to stop?
For example, because of tiredness,
pain, breathlessness or lack of
balance.
Use this space to tell us:
l how far you can move and why
you might have to stop
l if you usually use a walking stick,
crutches, a wheelchair or anything
else to help you, and tell us how it
affects the way you move around
Going up or down two steps
Can you go up or down two steps
without help from another person,
if there is a rail to hold on to?
If you have answered No or
It varies use this space to tell us
more about using steps.
Now go to question 2 on the next page.
50 metres – this is about the length of 5 double-decker buses,
or twice the length of an average public
swimming pool.
100 metres – this is about the length of a football pitch.
200 metres or more
It varies
No
Yes – now go to question 2 on the next page.
It varies
How your conditions affect you
Part 1 is about physical health problems
Part 2 is about mental health, cognitive and intellectual problems. By cognitive we mean problems you may
have with thinking, learning, understanding or remembering things.
Part 3 is about eating and drinking.
Part 1: Physical functions
8
ESA50 05/18
Part 1: Physical functions continued
2. Standing and sitting
Please tick this box if you can
stand and sit without difficulty.
Can you move from one seat to
another right next to it without
help from someone else?
While you are standing or sitting
(or a combination of the two)
how long can you stay in one
place and be pain free without
the help of another person?
This does not mean standing or
sitting completely still. It includes
being able to change position.
If you have answered No or
It varies use this space to tell us
more about standing and sitting and
why this might be difficult for you.
Please include:
l how long you can sit for
l how long you can stand for
l what might make sitting and
standing difficult for you
Now go to question 3 below.
No
Yes
It varies
Less than 30 minutes.
30 minutes to one hour.
More than one hour.
It varies
Only answer Yes to the following questions, if you can do the activity safely, to an acceptable standard,
asoften as you need to and in a reasonable length of time.
3. Reaching
Please tick this box if you can
reach up with either of your arms
without difficulty.
Can you lift at least one of your
arms high enough to put
something in the top pocket of
a coat or jacket while you are
wearing it?
Can you lift one of your arms
above your head?
If you have answered No or It varies
use this space to tell us:
l why you might not be able to
reach up
l does this affect both arms
Now go to question 4 on the next page.
No
Yes
It varies
No
Yes
It varies
9
ESA50 05/18
Part 1: Physical functions continued
Only answer Yes to the following questions, if you can do the activity safely, to an acceptable standard,
as often as you need to and in a reasonable length of time.
4. Picking up and moving things – using your upper body and either arm
Please tick this box if you can
pick things up and move them
without difficulty.
Can you pick up and move a
half-litre (one pint) carton full of
liquid using your upper body and
either arm?
Can you pick up and move a litre
(two pint) carton full of liquid
using your upper body and
eitherarm?
Can you pick up and move a large,
light object like an empty
cardboard box?
For example, from one surface to
another at waist height.
If you have answered No or
It varies
use this space to tell us:
l more about picking things up and
moving them
l why you might not be able to pick
things up
5. Manual dexterity (using your hands)
Please tick this box if you can use
your hands without any difficulty.
Can you use either hand to:
l press a button, such as a
telephone keypad
l turn the pages of a book
l pick up a £1 coin
l use a pen or pencil
l use a suitable keyboard or mouse?
Use this space to tell us:
l which of these things you have
problems with and why
l if it varies, tell us how
10
Now go to question 5 below.
No
Yes
It varies
No
Yes
It varies
No
Yes
It varies
Now go to question 6 on the next page.
Some of these things.
None of these things.
It varies
ESA50 05/18
Part 1: Physical functions continued
6. Communicating – speaking, writing and typing
By communicating, we don’t mean communicating in another language.
This section asks about how you can communicate with other people.
Please tick this box if you can
Now go to question 7 below.
communicate with other
people without any difficulty.
Can you communicate a simple
No
message to other people such as
Yes
the presence of something
dangerous?
It varies
This can be by speaking, writing,
typing or any other means, but
without the help of another person.
If you have answered No or It varies
use this space to tell us:
l how you communicate
l why you might not be able to
communicate with other people.
For example, difficulties with
speech, writing or typing
7. Communicating – hearing and reading
This section asks about your ability to hear other people and read printed information.
Please tick this box if you can
Now go to question 8 on the next page.
No
Yes
It varies
No
Yes
It v
aries
understand other people without
any difficulty.
Can you understand simple
messages from other people by
hearing or lip reading without the
help of another person?
A simple message means things like
someone telling you the location of
a fire escape.
Can you understand simple
messages from other people
by reading large size print or
using Braille?
If you have answered No or It varies
use this space to tell us if you need to
communicate in another way or use
aids, such as a hearing aid.
11
ESA50 05/18
Only answer Yes to the following questions, if you can do the activity safely, to an acceptable standard,
asoften as you need to and in a reasonable length of time.
Part 1: Physical functions continued
8. Getting around safely
This section asks about problems with your vision. If you normally use glasses or contact lenses, a guide dog or
any other aid, tell us how you manage when you are using them. Please also tell us how well you see in
daylight or bright electric light.
Please tick this box if you can get
around safely on your own.
Can you see to cross the road
safely on your own?
Can you safely get around a place
that you haven’t been to before
without help?
If you have answered No or It varies
use this space to tell us
l about your eyesight
l any problems you have finding
yourway around safely
Now go to question 9 below.
No
Yes
It varies
No
Yes
It varies
9. Controlling your bowels and bladder and using a collecting device
Please tick this box if you can
control your bowels and bladder
without any difficulty.
Do you have to wash or change
your clothes because of difficulty
controlling your bladder, bowels or
collecting device?
Collecting devices include stoma
bags and catheters.
Use this space to tell us
l about controlling your bowels and
bladder or managing your
collecting device
l if you experience problems if you
cannot reach a toilet quickly
l how often you need to wash or
change your clothes because of
difficulty controlling your bladder,
bowels or collecting device
12
Now go to question 10 on the next page.
No
Yes – weekly
Yes – monthly
Yes – less than monthly
Yes – but only if I cannot reach a toilet quickly
Only answer Yes to the following questions, if you can do the activity safely, to an acceptable standard,
asoften as you need to and in a reasonable length of time.
ESA50 05/18
Part 1: Physical functions continued
10. Staying conscious when awake
By staying conscious we do not mean falling asleep just because you are tired.
Please tick this box if you do not
have any problems staying
conscious while awake.
While you are awake, how often do
you faint or have fits or blackouts?
This includes epileptic seizures such
as fits, partial or focal seizures,
absences and diabetic hypos.
Tell us more about your fainting, fits
or blackouts in this space.
Now go to Part 2 on the next page.
Daily
Weekly
Monthly
Less than monthly
Only answer Yes to the following questions, if you can do the activity safely, to an acceptable standard,
asoften as you need to and in a reasonable length of time.
13
ESA50 05/18
You have now completed the section about your physical functions.
Part 2: Mental, cognitive and intellectual capabilities
In this part we ask how your mental health, cognitive or intellectual problems affect how you can do
things on a daily basis. By this we mean problems you may have from mental illnesses like schizophrenia,
depression and anxiety, or conditions like autism, learning difficulties, the effects of head injuries and
brain or neurological conditions.
If you have difficulties filling in this section, you can ask a friend, relative, carer or support worker to help you.
Y
ou can call Jobcentre Plus on 0800 169 0310 who will talk you through the questions over the phone.
Foronline help, visit www.chdauk.co.uk
If you would like any additional information to be considered, for example from your doctor, community
psychiatric nurse, occupational therapist, counsellor, psychotherapist, cognitive therapist, social worker,
support worker or carer please send it with this form. This includes information that tells us how your
disability, illness or health condition affects your ability to do things on a daily basis and information about
how this affects you when you are most unwell.
Only send us copies of medical or other information if you already have them. Don’t ask or pay for new
information or send us original documents. Please write your national insurance number on each piece of
information you send to us.
Please tick this box if you can
learn to do everyday tasks
without difficulty.
Can you learn how to do an
everyday task such as setting an
alarm clock?
Can you learn how to do a more
complicated task such as using a
washing machine?
If you have answered No or It varies
use this space to tell us:
l about any difficulties you have
learning to do tasks
l why you find it difficult
If you need more space you can use
the box on page 21 or a blank piece
of paper.
11. Learning how to do tasks
Now go to question 12 on the next page.
No
Yes
It varies
No
Yes
It varies
Only answer Yes to the following questions, if you can do the activity safely, to an acceptable standard,
asoften as you need to and in a reasonable length of time.
14
ESA50 05/18
Part 2: Mental, cognitive and intellectual capabilities continued
12. Awareness of hazards or danger
Please tick this box if you can stay
safe when doing everyday tasks
such as boiling water or using
sharp objects.
Do you need someone to stay
with you for most of the time
to stay safe?
If you have answered Yes or It varies
use this space to tell us
l how you cope with danger
l what problems you have with doing
things safely
Now go to question 13 below.
No
Yes
It varies
13. Starting and finishing tasks
This section asks about whether you can manage to start and complete daily routines and
tasks like cooking a meal or going shopping.
Please tick this box if you can
manage to do daily tasks without
difficulty.
Can you manage to plan, start and
finish daily tasks?
Use this space to tell us
l what difficulties you have doing
your daily routines. For example,
remembering to do things,
planning and organising how to
do them, and concentrating to
finish them
l what might make it difficult for
you and how often you need
other people to help you
l if it varies, tell us how
Now go to question 14 on the next page.
Never
Sometimes
It varies
Only answer Yes to the following questions, if you can do the activity safely, to an acceptable standard, as
often as you need to and in a reasonable length of time.
15
ESA50 05/18
14. Coping with changes
Please tick this box if you can cope
with changes to your daily routine.
Can you cope with small changes
to your routine if you know about
them before they happen?
For example, things like having a
meal earlier or later than usual, or
an appointment time being
changed.
Can you cope with small changes
to your routine if they are
unexpected?
This means things like your bus or
train not running on time, or a friend
or carer coming to your house
earlier or later than planned.
If you have answered No or It varies
use this space to tell us more about
how you cope with change. Explain
your problems, and give examples if
you can.
Part 2: Mental, cognitive and intellectual capabilities continued
Now go to question 15 below.
No
Yes
It varies
No
Yes
It varies
Only answer Yes to the following questions, if you can do the activity safely, to an acceptable standard,
asoften as you need to and in a reasonable length of time.
15. Going out
This question is about your ability to cope mentally or emotionally with going out. If you have physical problems
which mean you can’t go out, you should tell us about them in Part 1 (Physical functions) of this form.
Please tick this box if you can
go out on your own.
Can you leave home and go out
to places you know?
Can you leave home and go to
places you don’t know?
If you have answered No or
It varies use this space to tell
us
l why you cannot always get
to places
l if you need someone to go
with you
Explain your problems, and
give examples if you can.
16
Now go to question 16 on the next page.
No
Yes, if someone goes with me
It varies
No
Yes, if someone goes with me
It varies
ESA50 05/18
Part 2: Mental, cognitive and intellectual capabilities continued
Please tick this box if you can cope
with social situations without
feeling too anxious or scared.
Can you meet people you know
without feeling too anxious
or scared?
Can you meet people you don’t
know without feeling too anxious
or scared?
If you have answered No or It varies
use this space to tell us
l why you find it distressing to meet
other people
l what makes it difficult
l how often you feel like this
Explain your problems, and give
examples if you can.
16. Coping with social situations
By social situations we mean things like meeting new people and going to meetings or appointments.
Now go to question 17 below.
No
Yes
It varies
No
Yes
It varies
Please tick this box if your
behaviour does not upset
other people.
How often do you behave in a
way which upsets other people?
For example, this might be
because your disability, illness or
health condition results in you
behaving aggressively or acting in
an unusual way.
Use this space to tell us or provide
ex
amples of how your behaviour
upsets other people and how often
this happens. Explain your problems,
and give examples if you can. If it
varies, tell us how.
17. Behaving appropriately
This section asks about whether your behaviour upsets other people.
By this we do not mean minor arguments between couples.
Now go to question 18 on the next page.
Every day
Frequently
Occasionally
It varies
Only answer Yes to the following questions, if you can do the activity safely, to an acceptable standard,
asoften as you need to and in a reasonable length of time.
17
ESA50 05/18
18. Eating or drinking
Can you get food or drink to your
mouth without help or being
prompted by another person?
Can you chew and swallow food or
drink without help or being
prompted by another person?
If you have answered No or It varies
use this space to tell us about how
you eat or drink, and why you might
need help.
No
Yes
It varies
No
Yes
It varies
Part 3: Eating or drinking
Only answer Yes to the following questions, if you can do the activity safely, to an acceptable standard,
asoften as you need to and in a reasonable length of time.
18
ESA50 05/18
Face-to-face assessment
You may be asked to attend a face-to-face assessment with a qualified Healthcare Professional who
works for the Health Assessment Advisory Service. They will send you a letter with details of your
appointment and a leaflet that explains what happens at an assessment and who you can take with you.
If you are not asked to go to a face-to-face assessment, Jobcentre Plus will write to you and explain what
will happen with your claim. The Health Assessment Advisory Service will not write to you.
Please make sure you have put your telephone number and address details in the ‘About ‘You’ section
onpage 2.
You must let the Health Assessment Advisory Service know as soon as you get your appointment letter
ifyou need:
l a home visit. You will be asked for information from your medical professional to explain why you are
not able to travel to an assessment centre
l your assessment to be recorded on tape or CD. Requests will be accepted where possible. More details
about audio recording your assessment can be found at www.gov.uk and search for 'audio recording of
face-to-face assessments'
Please let the Health Assessment Advisory Service know at least two working days before your
assessment if you need:
l an assessment on the ground floor if you cannot use stairs unaided in an emergency
l a sign-language interpreter. You are welcome to bring your own sign language interpreter but they must
be 16 or over
l your face-to-face assessment with a Healthcare Professional of the same gender as you. For example,
on cultural or religious grounds. The Health Assessment Advisory Service will try their best to provide
one for you, but this may not always be possible
If you want more information about the face-to-face assessment, please visit www.chdauk.co.uk
Tell us about any other help you might need in the space below.
19
ESA50 05/18
No
Yes
No
Yes
No
Yes
If you do not understand English
or W
elsh, or cannot talk easily in
these languages, do you need
an interpreter?
You can bring your own interpreter
to the assessment, but they must be
over 16.
Tick this box if you will bring your
own interpreter.
Would you like your telephone
call in Welsh?
Would you like your face-to-face
assessment in Welsh?
Please tell us about any times or
dates in the next 3 months when
you cannot go to a face-to-face
assessment.
For example, because of a
hospitalappointment.
What language do you want to use?
Face-to-face assessment continued
20
ESA50 05/18
If you need to give us more information on a separate sheet of paper, please put your name and
National Insurance number on it.
Other information
If you need more space to answer any of the questions, please use the space below. If any of your carers,
friends or relatives want to add any information, they can do it here. This may be because they know the
effects your disability, illness or health condition have on how you can do things on a daily basis.
Please complete page 4 with their contact details as we may contact them for more information to support
your claim.
21
ESA50 05/18
Declaration
You may find it helpful to make a photocopy of your reply for future reference.
l I declare that I have read and understand the notes
at the front of this form, the information I have
given on this form is correct and complete.
l I understand that I must report all changes in my
circumstances which may affect my entitlement
promptly and by failing to do so I may be liable to
prosecution or face a financial penalty. I will phone
0800 169 0310, or write to the office that pays my
benefit, to report any change in my circumstances.
l If I give false or incomplete information or fail to
report changes in my circumstances promptly,
I understand that my Employment and Support
Allowance may be stopped or reduced and any
overpayment may be recovered. In addition, I may
be prosecuted or face a financial penalty.
l I agree that
– the Department for Work and Pensions
– any Healthcare Professional advising the
Department
– any organisation with which the Department has a
contract for the provision of assessment services
may ask any of the people or organisations I have
mentioned on this form for any information which is
needed to deal with
– this claim for benefit
– any request for this claim to be looked at again
and that the information may be given to that
Healthcare Professional or organisation or to the
Department or any other government body as
permitted by law.
l I also understand that the Department may use
the information which it has now or may get in the
future to decide whether I am entitled to
– the benefit I am claiming
– any other benefit I have claimed
– any other benefit I may claim in the future
l I agree to my doctor or any doctor treating me,
being informed about the Secretary of State's
determination on
– limited capability for work
– limited capability for work-related activity, or
– both
You must sign this form yourself if you can, even if
someone else has filled it in for you.
For people filling in this questionnaire for someone else
If you are filling in this questionnaire on behalf of someone else, please tell us some details about yourself.
Your name
Your address
Postcode
A phone number we can contact
you on
Please explain why you are filling
in the questionnaire for someone
else, which organisation, if any,
you represent, or your
connection to the person the
questionnaire is about.
Signature Date
22
ESA50 05/18
Please sign the form here
after printing
What to do next
Please make sure that:
l you have answered all the questions on this questionnaire that apply to you
l you have signed and dated the questionnaire
l you send back the questionnaire by the date we’ve asked you to in the enclosed letter
l you return the completed questionnaire using the enclosed envelope. It doesn't need a stamp. Do not
send it or take this to your Jobcentre Plus office
l you have provided any additional evidence or information that you feel will help us to understand how
your disability, illness or health condition affects how you can do things on a daily basis
How the Department for Work and Pensions collects and uses information
When we collect information about you we may use it for any of our purposes. These include
dealing with:
l benefits and allowances
l child maintenance
l employment and training
l financial planning for retirement
l occupational and personal pension schemes
We may get information about you from others for any of our purposes if the law allows us to do so.
We may also share information with certain other organisations if the law allows us to.
To find out more about how we use information, contact any of our offices or visit our website at
www.gov.uk/dwp/personal-information-charter
What happens next
Please post your completed form to the Health Assessment Advisory Service in the envelope enclosed.
The Health Assessment Advisory Service may contact you to arrange a face-to-face appointment for you
with a Healthcare P
rofessional.
23
ESA50 05/18
Cancer treatment – for completion by a Healthcare Professional which may include a GP,
hospital doctor or clinical nurse who is aware of your condition.
The information you provide on this page is important as it will help us make a quick
decision about your patient's Employment and Support Allowance claim.
This page concerns patients who are having, waiting for or recovering from chemotherapy
or radiotherapy.
Please complete the rest of this page. If you want more information about Employment and Support
Allowance, go to www.gov.uk/employment-support-allowance
Details of cancer diagnosis
Include
l type and site
l stage
l any related diagnoses
Details of treatment
Include
l regime
l expected duration
Is your patient:
(Please tick as appropriate.)
In your opinion, is it likely that the
impact of the treatment has or will
have work-limiting side effects?
Signature
Date
Your details:
Name
Job title and qualifications
Surgery stamp, hospital stamp or address details:
No
Yes
In your opinion, are these side effects
likely to limit all work?
No
awaiting or undergoing chemotherapy or radiotherapy?
recovering (post completion of treatment)
from chemotherapy or radiotherapy?
Yes
In your opinion, how long would you
expect these side effects to last?
24
ESA50 05/18
Please sign the form here after printing
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Esa-50-capability-for-work-questionnaire ESA50 - capability for work questionnaire

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Completed 19 November 2019

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