Fillable Capability for Work questionnaire (Cabinet Office)

Fill Online, Printable, Fillable, Blank Capability for Work questionnaire (Cabinet Office) Form

Use Fill to complete blank online CABINET OFFICE pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

Capability for Work questionnaire (Cabinet Office)

On average this form takes 56 minutes to complete

The Capability for Work questionnaire (Cabinet Office) form is 36 pages long and contains:

  • 0 signatures
  • 24 check-boxes
  • 214 other fields

Country of origin: UK
File type: PDF

Use our library of forms to quickly fill and sign your Cabinet Office forms online.

BROWSE CABINET OFFICE FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
Capability for Work
questionnaire
If you would like this questionnaire in Braille, large print or audio, please call Universal Credit
on the number at the top of any letters we have sent you or use your online journal if you have
one to tell us what you need.
If you live in Wales and want this questionnaire in Welsh please call us on 0800 328 1744
What you need to do:
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.
You must send it back by the date we’ve asked you to in the enclosedletter.
Read this questionnaire carefully and make sure you answer all the questions in full.
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 UC50.
Return the completed questionnaire using the enclosed envelope. Itdoes not need a stamp.
Do not send it or take this to your JobcentrePlus office as this could delay the Health
Assessment Advisory Service processing your assessment
Send copies of all your medical or other information back with your questionnaire. We do not
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.
Only send us copies of medical or other information if you already have them. Do not 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.
Make sure you fill in the About you section on page 2 in full
If you need help lling in the questionnaire, you can:
ask a friend, relative, carer or support worker to helpyou
call Universal Credit on the number at the top of any letters we have sent you or Use your
online journal, if you have one, to ask questions. Please do not go into your local Jobcentre
Plus ofce
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.
If you do not ll in and send back this questionnaire to the Health Assessment
Advisory Service by the date we have asked you to, then we may not have
enough information to make a decision on your capability for work and you may
not get the right amount of Universal Credit.
Universal Credit is operated by the Department for Work and Pensions
UC50 
About you
Surname
Other names
Title
Address
Date of birth
National Insurance (NI) number
A phone number we can contact
you on
Email address, if you have one.
Please ll in this form with BLACK INK and in CAPITALS.
Mr/Mrs/Miss/Ms/Other title
Postcode
Letters Numbers Letter
Have you been in hospital for over
No
Go to the next question.
28 days in the last 12 months?
Yes
Please tell us the dates you were
in hospital.
From To
What was the name of the
hospital.
Have you served in HM Forces?
No
Go to the next question.
Yes
Royal Navy/Marines
Which service were you in?
Army
RAF
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
nd your medical records more
quickly. We will not share or
use this information for any
other purpose.
Go to the next question.
No
Yes
Are you pregnant?
No
Yes
When is your baby due?
UC50 
Universal Credit is operated by the Department for Work and Pensions
2
If you are returning this questionnaire late
If you do not fill in and send back this questionnaire to the Health Assessment Advisory Service
by the date we have asked you to, then we may not have enough information to make a
decision on your capability for work and you may not get the right amount of Universal Credit.
Are you sending this questionnaire
No
back later than the date we asked
Yes
Please tell us why:
you to in the enclosed letter?
Universal Credit is operated by the Department for Work and Pensions
UC50 12/20
3
About your General Practitioner (GP) or doctor’s surgery
Please tell us about your GP. If you do not 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 do not 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.
Do not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
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 do not
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. Do not 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:
consultant or specialist doctor
psychiatrist
specialist nurse, such as Community Psychiatric Nurse
physiotherapist
occupational therapist
social worker
support worker or personal assistant
carer
Their name
Their job title
Their address
Their phone number
Postcode
UC50 12/20
Universal Credit is operated by the Department for Work and Pensions
4
About medical or other information you may already have
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:
GPs scans
hospital doctors audiology
specialist nurses the results of x-rays, but not the x-rays
community psychiatric nurses themselves
occupational therapists
physiotherapists
Things like:
social workers
your current prescription list
support workers
your statement of special educational needs
learning disability support teams
epilepsy seizure diary
counsellors or carers
your certicate of visual impairment
Other information:
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.
Education Health Plans.
A diary of your symptoms if your disability, illness or health condition varies from day to day.
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. Do not
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.
Things the Health Assessment Advisory Service do not need to see
General information about your medical conditions Internet printouts
that are not about you personally. Such as: Statement of Fitness for Work, otherwise
Photographs known as fit notes, medical certificates,
Letters about other benets doctor’s statements or sick notes
Fact sheets about your medication Appointment letters
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?
Go to About your disabilities, illnesses or health
No
conditions on page 6.
Please go to the next question.
Yes
Go to About your disabilities, illnesses or health
Are you having, waiting for or
No
conditions on page 6.
recovering from chemotherapy or
radiotherapy treatment for cancer?
Yes
Please make sure page 24 is lled 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 lled in and signed by
No
Do you have other health problems,
your Healthcare Professional and you’ve signed page 22.
as well as cancer and the problems
You can then return this questionnaire using the enclosed
resulting from your cancer
envelope.
treatment?
Yes
Please ll in the rest of this questionnaire.
Universal Credit is operated by the Department for Work and Pensions
UC50 12/20
5
About your disabilities, illnesses or health conditions
We will ask you specic 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:
what your disabilities. illnesses
or health conditions are
how they affect you
when they started
if you think any of your
conditions are linked to drugs or
alcohol
Please tell us about:
any aids you use, such as a
wheelchair or hearing aid
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.
UC50 12/20
Universal Credit is operated by the Department for Work and Pensions
6
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.
Hospital, clinic or special treatment like dialysis or rehabilitation treatment
Use this section to tell us about any:
hospital or clinic treatment you are having
hospital or clinic treatment you expect to have in the near future
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.
Tell us about all your hospital,
clinic or special treatment.
For example
what treatment you are having
where you go to get the treatment
how often you go for the
treatment.
If you are expecting to have
treatment in the near future, tell us
what the treatment will be
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
No
Go to Part 1 on the next page.
treatment which needs you to stay
Tell us about this below.
Yes
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
Go to Part 1 on the next page.
No
aresidential rehabilitation
Tell us the name of the organisation running your
scheme, when your treatment began, or is due to begin,
scheme?
Yes
If you need more space, use the
and when you expect it to end.
space on page 21 or a separate
sheet of paper.
Universal Credit is operated by the Department for Work and Pensions
UC50 12/20
7
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
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:
how far you can move and why
you might have to stop
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?
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
If you have answered No or
It varies use this space to tell us
more about using steps.
UC50 12/20
Universal Credit is operated by the Department for Work and Pensions
8
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.
2. Standing and sitting
Please tick this box if you can
Now go to question 3 below.
stand and sit without difficulty.
Can you move from one seat to
No
another right next to it without
help from someone else?


While you are standing or sitting
0
(or a combination of the two)
0
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:
how long you can sit for
how long you can stand for
what might make sitting and
standing difficult for you
3. Reaching
Please tick this box if you can
Now go to question 4 on the next page.
reach up with either of your arms
without difficulty.
Can you lift at least one of
No
your arms high enough to put
Yes
something in the top pocket of
a coat or jacket while you are
It varies
wearing it?
Can you lift one of your arms
No
above your head?
Yes
It varies
If you have answered No or It varies
use this space to tell us:
why you might not be able to
reach up
does this affect both arms
Universal Credit is operated by the Department for Work and Pensions
UC50 12/20
9
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:
more about picking things up and
moving them
why you might not be able to pick
things up
Now go to question 5 below.
No
Yes
It varies
No
Yes
It varies
No
Yes
It varies
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:
press a button, such as a
telephone keypad
turn the pages of a book
pick up a £1 coin
use a pen or pencil
use a suitable keyboard or mouse?
Use this space to tell us:
which of these things you have
problems with and why
ifit varies, tell us how.
Now go to question 6 on the next page
No
Yes
It varies
UC50 12/20
Universal Credit is operated by the Department for Work and Pensions
10
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.
6. Communicating – speaking, writing and typing
By communicating, we do not mean communicating in another language.
This section asks about how you can communicate with other people.
Please tick this box if you can
communicate with other people
without any difficulty.
Can you communicate a simple
message to other people such
as the presence of something
dangerous?
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:
how you communicate
why you might not be able to
communicate with other people.
For example, difculties with
speech, writing or typing
Now go to question 7 below.
No
Yes
It varies
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
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 re 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.
Now go to question 8 on the next page.
No
Yes
It varies
No
Yes
It varies
Universal Credit is operated by the Department for Work and Pensions
UC50 12/20
11
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.
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
Now go to question 9 below.
around safely on your own.
Can you see to cross the road
No
safely on your own?
Yes
It varies
Can you safely get around a place
No
that you have not been to before
Yes
without help?
It varies
If you have answered No or It varies
use this space to tell us:
about your eyesight
any problems you have nding
yourway around safely
9. Controlling your bowels and bladder and using a collecting device
Please tick this box if you can
Now go to question 10 on the next page.
control your bowels and bladder
without any difficulty.
Do you have to wash or change
No
your clothes because of difficulty
controlling your bladder, bowels or
Yes – weekly
collecting device?
Yes – monthly
Collecting devices include stoma
bags and catheters.
Yes – less than monthly
Yes – but only if I cannot reach a toilet quickly
Use this space to tell us:
about controlling your bowels
and bladder or managing your
collecting device
if you experience problems if you
cannot reach a toilet quickly
how often you need to wash or
change your clothes because of
difficulty controlling your bladder,
bowels or collecting device
UC50 12/20
Universal Credit is operated by the Department for Work and Pensions
12
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.
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
Now go to Part 2 on the next page.
not have any problems staying
conscious while awake.
Daily
While you are awake, how often do
you faint or have fits or blackouts?
Weekly
This includes epileptic seizures such
Monthly
as ts, partial or focal seizures,
absences and diabetic hypos.
Less than monthly
Tell us more about your fainting, ts
or blackouts in this space.
You have now completed the section about your physical functions.
Universal Credit is operated by the Department for Work and Pensions
UC50 12/20
13
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.
You can call Universal Credit on the number at the top of any letters we have sent you. They will talk you
through the questions over the phone or you can Use your online journal, if you have one, to ask questions.
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. Do not 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.
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.
11. Learning how to do tasks
Please tick this box if you can
Now go to question 12 on the next page.
learn to do everyday tasks
without difficulty.
Can you learn how to do an
No
everyday task such as setting an
Yes
alarm clock?
It varies
No
Can you learn how to do a more
complicated task such as using a
Yes
washing machine?
It varies
If you have answered No or It varies
use this space to tell us:
about any difculties you have
learning to do tasks
why you nd it difcult
If you need more space you can use
the box on page 21 or a blank piece
of paper.
UC50 12/20
Universal Credit is operated by the Department for Work and Pensions
14
Part 2: Mental, cognitive and intellectual capabilities 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.
12. Awareness of hazards or danger
Please tick this box if you can stay
Now go to question 13 below.
safe when doing everyday tasks
such as boiling water or using
sharp objects.
Do you need someone to stay
No
with you for most of the time
Yes
to stay safe?
It varies
If you have answered Yes or It varies
use this space to tell us:
how you cope with danger
what problems you have with doing
things safely
13. Starting and nishing tasks
This section asks about whether you can manage to start and complete daily routines and
tasks like cooking a meal or going shopping.
Now go to question 14 on the next page.
Please tick this box if you can
manage to do daily tasks without
difficulty.
Can you manage to plan, start and
Never
finish daily tasks?
Sometimes
It varies
Use this space to tell us:
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
what might make it difficult for
you and how often you need
other people to help you
ifit varies, tell us how
Universal Credit is operated by the Department for Work and Pensions
UC50 12/20
15
Part 2: Mental, cognitive and intellectual capabilities 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.
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.
Now go to question 15 below.
No
Yes
It varies
No
Yes
It varies
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 cannot 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 do not know?
If you have answered No or
It varies use this space to tell
us:
why you cannot always get
to places
if you need someone to go
with you
Explain your problems, and
give examples if you can.
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
UC50 12/20
Universal Credit is operated by the Department for Work and Pensions
16
Part 2: Mental, cognitive and intellectual capabilities 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.
16. Coping with social situations
By social situations we mean things like meeting new people and going to meetings or appointments.
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 do not
know without feeling too anxious
or scared?
Now go to question 17 below.
No
Yes
It varies
No
Yes
It varies
If you have answered No or It varies
use this space to tell us:
why you nd it distressing to meet
other people
what makes it difcult
how often you feel like this
Explain your problems, and give
examples if you can.
17. Behaving appropriately
This section asks about whether your behaviour upsets other people.
By this we do not mean minor arguments between couples.
Please tick this box if your
behaviour does not upset
Now go to question 18 on the next page.
other people.
How often do you behave in a
Every day
way which upsets other people?
For example, this might be
Frequently
because your disability, illness or
Occasionally
health condition results in you
behaving aggressively or acting in
It varies
an unusual way.
Use this space to tell us or provide
examples 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.
Universal Credit is operated by the Department for Work and Pensions
UC50 12/20
17
Universal Credit is operated by the Department for Work and Pensions
18. Eating or drinking
Can you get food or drink to your
mouth without help or being
prompted by another person?
No
Yes
No
Can you chew and swallow food
or drink without help or being
prompted by another person?
Yes
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.
Part 3: Eating or drinking
It varies
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.
18
UC50 12/20
Sharing information about your health condition
The Department for Work and Pensions (DWP) or
approved healthcare professionals that work for
DWP, might need more information about your
health condition and how it affects your ability to
work.
They might ask for relevant information from your
doctor, or any other relevant professional you tell
them about.
Do you give your consent for your doctor or
other relevant professionals to give DWP more
information about your health condition?
How DWP uses this information
DWP uses this information to:
• process for claim
• make a decision on your claim, or any mandatory
reconsideration or appeal you make.
The law allows DWP to get, keep and use this
information.
Your doctor (or the relevant professionals you tell
DWP about) needs your consent to give information
to DWP. If you give your consent, this lets them
know that they are legally allowed to share this
information with DWP.
DWP can lawfully ask your doctor, hospital
consultant or other relevant professionals for
information about your health condition and how
it affects you. This is because we are asking for the
information to help us carry out our official social
security functions.
You do not have to give your consent. If you do not,
DWP will make a decision based on the information
they have already, as well as any you give them
yourself.
If you change your mind
You can change your mind. You can do this by going
to your online journal to report a change or phone
Universal Credit on 0800 3285644 and say you want
to give or withdraw your consent. If you withdraw
your consent, DWP cannot get information from your
doctor or others named on your form.
I have read and understood the text above.
Yes - information about my health can
be shared with DWP or the healthcare
professionals that work for them.
No - information about my health cannot be
shared with DWP or the healthcare
professionals that work for them.
Signature
Date
Please sign here
Universal Credit is operated by the Department for Work and Pensions
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, Universal Credit 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:
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
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:
an assessment on the ground floor if you cannot use stairs unaided in an emergency
a sign-language interpreter. You are welcome to bring your own sign language interpreter but they
must be 16 or over
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
UC50 12/20
Face-to-face assessment continued
If you do not understand English
or Welsh, 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.
No
What language do you want to use?
Yes
No
Yes
No
Yes
UC50 12/20
Universal Credit is operated by the Department for Work and Pensions
20
Universal Credit is operated by the Department for Work and Pensions
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.
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
21
UC50 12/20
Universal Credit is operated by the Department for Work and Pensions
Consent to notify your GP of the outcome of the Work Capability Assessment
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.
I understand that I must report all changes in
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 report
any change in my circumstances via my online
journal for Universal Credit or by phoning 0800
3285644.
If I give false or incomplete information or fail
to report changes in my circumstances promptly,
I understand that my Universal Credit may be
stopped or reduced and any overpayment may be
recovered. In addition, I may be prosecuted or face
a financial penalty.
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.
DWP would like to share its decision based on the
result of your Work Capability Assessment (WCA) with
your doctor, or any doctor treating you. This will help
the doctor, as it will tell them when they no longer
need to provide you with Statements of Fitness for
Work (also known as fit notes or medical certificates)
for the purposes of this claim.
We need your agreement to share this information.
You do not have to give your agreement, if you do not
agree it will not affect your claim for Universal Credit.
You can change your mind any time before the
medical assessment. If you do, go to your online
journal to report a change or phone Universal Credit
on 0800 3285644 and say you want to give or
withdraw your consent.
If you contact us after the assessment it may be too
late, as we may have already made a decision and
shared it.
If you withdraw your agreement, we will not share
the decision based on the outcome of your WCA with
your doctor.
I agree to my doctor, or any other doctor treating
me, being informed about the result of my Work
Capability Assessment.
Declaration
Signature Date
22
UC50 12/20
Yes
No
Signature
Date
You may nd it helpful to make a photocopy of your reply for future reference.
You must sign this form yourself if you can, even if
someone else has lled it in for you.
Please sign here
Please sign here
For people filling in this questionnaire for someone else
If you are lling 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.
What to do next
Please make sure that:
you have answered all the questions on this questionnaire that apply to you
you have signed and dated the questionnaire
you send back the questionnaire by the date we’ve asked you to in the enclosed letter
you return the completed questionnaire using the enclosed envelope. It does not need a stamp. Do not
send it or take this to your Jobcentre Plus office
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:
social security benets and allowances
child maintenance
employment and training
investigating and prosecuting tax credits offences
private pensions policy
retirement planning
We may get information about you from other parties for any of our purposes as the law allows to
check the information you provide and improve our services. We may give information about you to
other organisations as the law allows, for example to protect against crime.
To nd out more about our purposes, how we use personal information for those purposes and your
information rights, including how to request a copy of your information, please see DWP’s Personal
Information Charter on GOV.UK
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 Professional.
Universal Credit is operated by the Department for Work and Pensions
UC50 12/20 23
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 Universal Credit 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 Universal Credit, go to
www.gov.uk/
universal-credit
Details of cancer diagnosis
Include:
type and site
stage
any related diagnoses
Details of treatment
Include:
regime
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?
In your opinion, how long would you
expect these side effects to last?
Your details:
Name
awaiting or undergoing chemotherapy or radiotherapy?
recovering (post completion of treatment)
from chemotherapy or radiotherapy?
No
Yes
In your opinion, are these side effects
likely to limit all work?
No
Yes
Surgery stamp, hospital stamp or address details:
Job title and qualifications
Signature
Date
UC50 12/20
Universal Credit is operated by the Department for Work and Pensions
24
Please sign here
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

Capability for Work questionnaire (Cabinet Office)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 17 August 2021

Message

View Audit Log
Print With Audit Log
Duplicate Document