Capability for Work questionnaire

Fill in the Capability for Work questionnaire and send it back to the Health Assessment Advisory Service to determine if you need a face-to-face assessment. Get the best support and benefits.

Capability for Work questionna
We have many ways we can communicate with you.
If you would like braille, British Sign Language, email, a hearing loop,
translations, large print, audio or something else please call us 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.
Equality and diversity
We are committed to treating people fairly, regardless of their disability, ethnicity,
sex, sexual orientation, transgender status, marital or civil partnership status, age,
religion or beliefs. Please contact us if you have any concerns.
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 have 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 ESA50.
• return the completed questionnaire using the enclosed envelope. It does not
need a stamp. Do not send it or take it to your Jobcentre Plus office.
• 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.
01/21 1 ESA50

If you need help filling in the questionnaire, you can:
• ask a friend, relative, carer or support worker to help you
• 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 do not fill in this questionnaire and send it to the Health
Assessment Advisory Service by the date we have asked you to.
About you
01 Surname
02 Other names
03 Title
Mr, Mrs, Miss, Ms, or other.
04 Address
Postcode
05 Date of birth
DD/MM/YYYY
06 National Insurance (NI) Number
07 A phone number we can contact
you on
08 Email address
If you have one.
09 Have you been in hospital for over
28 days in the last 12 months?
No Go to question 10
Yes
Please tell us the dates you were
in hospital. DD/MM/YYYY
From
To
What was the name of the hospital?
2 ESA50
Alexandru
Aron
Mr
Hendon Way 228
NW4 3NE
07/09/1982
S Y 4 3 5 5 1 5 D
02081338788
[e-mail]
19/08/2022
30/09/2022
Barnet Hospital

10 Have you served in H M Forces?
No Go to question 11
Yes
Which service were you in?
Army
Royal Navy/Marines
RAF
What date did you leave?
DD/MM/YYYY
11 Have you been released from prison
in the last 6 months?
This information will help us find your
medical records more quickly. We will
not share or use this information for
any other purpose.
No Go to question 12
Yes
What date did you leave?
DD/MM/YYYY
12 Are you pregnant?
No
Yes
When is your baby due?
DD/MM/YYYY
If you are returning this questionnaire late
Your Employment and Support Allowance (ESA) payments may stop if you do not fill i
this questionnaire and send it to the Health Assessment Advisory Service. It is import
that you send it back by the date we have asked you to in the enclosed letter.
13 Are you sending this questionnaire back later than the date
we asked you to in the enclosed letter?
No
Yes Please tell us why:
3 ESA50
Health Problems
Long-term effects of coronavirus ( long COVID )
post-COVID-19 syndrome

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 is 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.
14 What is your GP’s name or the name
of your doctor’s surgery?
15 Their address
Postcode
16 Their phone number
About other Healthcare Professionals, carers, friends or relati
know the most about your disability, illness or health conditio
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 affect 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 is 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
17 Their name
18 Their job title
19 Their address
Postcode
20 Their phone number
4 ESA50
Dr. Azim and Partners
67 Elliot Rd.
NW4 3EB
02084573950

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:
• GPs
• hospital doctors
• specialist nurses
• community psychiatric nurses
• occupational therapists
• physiotherapists
• social workers
• support workers
• learning disability support teams
• counsellors or carers.
Medical test results including:
• scans
• audiology
• the results of x-rays, but not
the x-rays themselves.
Things like:
• your current prescription list
• your statement of special educational needs
• epilepsy seizure diary
• your certificate 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
• 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 that are not about you personally.
Such as:
• photographs
• letters about other benefits
• fact sheets about your medication
• internet printouts
• statement of Fitness for Work, otherwise
known as fit notes, medical certificates,
doctor’s statements or sick notes
• appointment letters.
3
5
5 ESA50

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.
21 Do you have cancer?
No Go to ‘About your disabilities,
illnesses or health conditions’
on page 7
Yes Go to question 22
22 Are you having, waiting for or
recovering from chemotherapy or
radiotherapy treatment for cancer?
No Go to ‘About your disabilities,
illnesses or health conditions’
on page 7
Yes Please make sure page 27 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 28 and you have
signed page 25 you can then
return this questionnaire using
the enclosed envelope.
23 Do you have other health problems,
as well as cancer and the problems
resulting from your cancer treatment?
No Please make sure page 27 has
been filled in and signed by
your Healthcare Professional
and you have signed page
25. You can then return
this questionnaire using the
enclosed envelope.
Yes Please fill in the rest of this
questionnaire.
6 ESA50

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.
24 What are your disabilities, illnesses or health conditions?
Tell us how they affect you, when they started and if you think any of your
conditions are linked to drugs or alcohol.
Also tell us about any aids you use, such as a wheelchair or hearing aid and anything
else you think we should know about your disabilities, illnesses or health conditions.
If you need more space, please use page 24 or a separate sheet of paper with your
National Insurance Number written on it.
7 ESA50
Long-term effects of coronavirus ( long COVID )
post-COVID-19 syndrome
Bone pain, I can barely move

25 What tablets, liquids, inhalers or other medication are you taking and
are there any side effects?
You can find a list of your medications on your latest prescription. If you need more spac
please use page 24 or a separate sheet of paper with your National Insurance Number
written on it.
Hospital, clinic or special treatment like dialysis or rehabilitat
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.
26 What hospital, clinic or special treatments are you getting?
For example, the treatment you are having, where you get it and how often.
If you are expecting to have treatment in the near future, tell us what the
treatment will be and the date it is due to start.
If you need more space, please use page 24 or a separate sheet of paper with
your National Insurance Number written on it.
8 ESA50

27 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 24 or a separate sheet of paper
with your National Insurance Number
written on it.
No Go to Part 1
Yes Tell us about this below.
28 Are you in, or due to start a residentia
rehabilitation scheme?
If you need more space, use the space
on page 24 or a separate sheet of paper
with your National Insurance Number
written on it.
No Go to Part 1
Yes 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.
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.
29 Please tick this box if you can move around and use steps without difficulty.
Go to question 34
9 ESA50
Therapy in the hospital

30 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.
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
31 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, tell us how it affects
the way you move around.
32 Can you go up or down 2 steps
without help from another person,
if there is a rail to hold on to?
No
Yes Go to question 34
It varies
33 If you have answered No or It varies,
tell us more about using steps.
10 ESA50
I can walk to the bathroom and back to bed
I have bone pain

2. Standing and sitting
34 Please tick this box if you can stand
and sit without difficulty.
Go to question 38
35 Can you move from one seat to
another right next to it without help
from someone else?
No
Yes
It varies
36 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.
Less than 30 minutes
30 minutes to 1 hour
More than 1 hour
It varies
37 If you have problems with standing
and sitting, tell us more about it. Tell
us why this might be difficult for you
and how this affects your typical day.
Please include how long you can sit
for, how long you can stand for and
what might make sitting and standing
difficult for you.
3. Reaching
38 Please tick this box if you can reach
up with either of your arms without
difficulty.
Go to question 42
39 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?
No
Yes
It varies
40 Can you lift one of your arms above
your head?
No
Yes
It varies
41 If you have answered No or It varies,
tell us why you might not be able to
reach up and if this affects both arms.
11 ESA50
I can walk to the bathroom and back to bed and
I have bone pain
I can walk to the bathroom and back to bed and
I have bone pain

4. Picking up and moving things
– using your upper body and
either arm
42 Please tick this box if you can pick
things up and move them without
difficulty.
Go to question 47
43 Can you pick up and move a half-litre
(1 pint) carton full of liquid using your
upper body and either arm?
No
Yes
It varies
44 Can you pick up and move a litre
(2 pint) carton full of liquid using
your upper body and either arm?
No
Yes
It varies
45 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.
No
Yes
It varies
46 If you have answered No or It varies,
tell us more about picking things up
and moving them and why you might
not be able to pick things up.
5. Manual dexterity (using
your hands)
47 Please tick this box if you can use
your hands without any difficulty.
Go to question 50
48 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 or use a
suitable keyboard or mouse?
Some of these things
None of these things
It varies
49 If you have answered Some of these
things or It varies, tell us more about
picking things up and moving them
and why you might not be able to
pick things up.
Tell us which of these things you have
problems with and why. If it varies, tell
us how.
12 ESA50
Bone Pain
If I move for more than 5 minutes, I have pain in
my body and faint

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.
50 Please tick this box if you can
communicate with other people
without any difficulty.
Go to question 53
51 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.
No
Yes
It varies
52 If you have answered No or It varies,
tell us how you communicate and
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.
53 Please tick this box if you can
understand other people without
any difficulty.
Go to question 57
54 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.
No
Yes
It varies
55 Can you understand simple messages
from other people by reading large
size print or using braille?
No
Yes
It varies
56 If you have answered No or It varies,
tell us more about if you need to
communicate in another way or
use aids, such as a hearing aid.
13 ESA50

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.
57 Please tick this box if you can get
around safely on your own.
Go to question 61
58 Can you see to cross the road
safely on your own?
No
Yes
It varies
59 Can you safely get around a place
that you have not been to before
without help?
No
Yes
It varies
60 If you have answered No or It varies,
tell us about your eyesight and any
problems you have finding your way
around safely.
9. Controlling your bowels
and bladder and using a
collecting device
61 Please tick this box if you can control
your bowels and bladder without
any difficulty.
Go to question 64
62 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.
No
Yes – weekly
Yes – monthly
Yes – less than a month
Yes –but only if I cannot
reach a toilet quickly
63 Tell us about controlling your bowels
and bladder or managing your
collecting device and if you experience
problems if you cannot reach a toilet
quickly. Tell us how often you need to
wash or change your clothes because
of difficulty controlling your bladder,
bowels or collecting device.
14 ESA50
If I move for more than 5 minutes, I have pain in
my body and faint

10. Staying conscious when awake
By staying conscious we do not mean
falling asleep just because you are tired.
64 Please tick this box if you do not
have any problems staying
conscious while awake.
Go to Part 2
65 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.
Daily
Weekly
Monthly
Less than monthly
15 ESA50
66 Tell us more about your fainting, fits
or blackouts.

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 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. 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
67 Please tick this box if you can learn to
do everyday tasks without difficulty.
Go to question 71
68 Can you learn how to do an everyday
task such as setting an alarm clock?
No
Yes
It varies
69 Can you learn how to do a more
complicated task such as using a
washing machine?
No
Yes
It varies
70 If you have answered No or It varies,
tell us about any difficulties you
have learning to do tasks and why
you find it difficult.
If you need more space you can use
the box on page 21 or a separate sheet
of paper with your National Insurance
Number written on it.
16 ESA50

12. Awareness of hazards or danger
71 Please tick this box if you can stay safe
when doing everyday tasks such as
boiling water or using sharp objects.
Go to question 74
72 Do you need someone to stay with you
most of the time for you to stay safe?
No
Yes
It varies
73 If you have answered No or It varies,
tell us about how you cope with
danger and what problems you
have with doing things safely.
13. Starting and finishing tasks
This is about whether you can manage
to start and complete daily routines
and tasks like cooking a meal or
going shopping.
74 Please tick this box if you can manage
to do daily tasks without difficulty.
Go to question 77
75 Can you manage to plan, start
and finish daily tasks?
Never
Sometimes
It varies
76 Tell us about 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. Tell us
what might make it difficult for you and
how often you need other people to help
you. If it varies, tell us how.
17 ESA50
If I move for more than 5 minutes, I have pain in
my body and faint
If I move for more than 5 minutes, I have pain in
my body and faint

14. Coping with changes
77 Please tick this box if you can cope
with changes to your daily routine.
Go to question 81
78 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.
No
Yes
It varies
79 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.
No
Yes
It varies
80 If you have answered No or It varies,
tell us more about how you cope with
change. Explain your problems, and
give examples if you can.
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.
81 Please tick this box if you can go out
on your own.
Go to question 85
82 Can you leave home and go out to
places you know?
No
Yes, if someone goes with me
It varies
83 Can you leave home and go to places
you do not know?
No
Yes, if someone goes with me
It varies
84 If you have answered No or It varies,
tell us why you cannot always get to
places and if you need someone to go
with you. Explain your problems, and
give examples if you can.
18 ESA50
If I move for more than 5 minutes, I have pain in
my body and faint

16. Coping with social situations
By social situations we mean things
like meeting new people and going to
meetings or appointments.
85 Please tick this box if you can cope
with social situations without feeling
too anxious or scared.
Go to question 89
86 Can you meet people you know
without feeling too anxious or scared?
No
Yes
It varies
87 Can you meet people you do not know
without feeling too anxious or scared?
No
Yes
It varies
88 If you have answered No or It varies,
tell us why you find it distressing to
meet other people, what makes it
difficult and 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.
89 Please tick this box if your behaviour
does not upset other people.
Go to Part 3
90 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.
Every day
Frequently
Occasionally
It varies
91 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.
19 ESA50

20 ESA50
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.
92 Can you get food or drink to your
mouth without help or being
prompted by another person?
No
Yes
It varies
93 Can you chew and swallow food
or drink without help or being
prompted by another person?
No
Yes
It varies
94 If you have answered No or It varies,
tell us about how you eat or drink
and why you might need help.

21 ESA50
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 consent for your doctor or
other relevant professionals to give DWP
more information about your health
condition?
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.
How DWP uses this information
DWP uses this information to:
• process your 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 other 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
calling 0800 169 0310 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.
Signature
Date
DD/MM/YYYY
Alexandru Aron
01/10/2022

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 phone
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 2 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
95 Tell us about any other help you might need.
22 ESA50

96 If you do not understand English or
Welsh, or cannot talk easily in these
languages, do you need an interpreter?
No
Yes
What language do you want to use?
You can bring your own
interpreter to the assessment,
but they must be 16 or over.
Do you want to bring your
own interpreter?
No
Yes
97 Would you like your telephone
call in Welsh?
No
Yes
98 Would you like your face-to-face
assessment in Welsh?
No
Yes
99 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.
23 ESA50
All the times
If I move for more than 5 minutes, I have pain in
my body and faint

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.
If you need to give us more information on a
separate sheet of paper, please put your name
and National Insurance Number on it.
24 ESA50

Consent to notify your GP
of the outcome of the Work
Capability Assessment
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 ESA. We will keep a record of the
decision you make.
You can withdraw your agreement at any time
before the medical assessment takes place by
calling DWP on 0800 169 0310.
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.
No
Yes
Signature
Date
DD/MM/YYYY
Declaration
You may find it helpful to make a photocop
of your reply for future reference.
• 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 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.
• 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.
• 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.
You must sign this form yourself if you can
even if someone else has filled it in for you
Signature
Date
DD/MM/YYYY
25 ESA50
Alexandru Aron
01/10/2022
Alexandru Aron
01/10/2022

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.
100 Your name
101 Your address
Postcode
102 A phone number we can contact you on
103 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
• have signed and dated the questionnaire
• send back the questionnaire by the date we
have asked you to in the enclosed letter
• send back the completed questionnaire
using the enclosed envelope. It does not
need a stamp. Do not send it or take it to
your Jobcentre Plus office
• 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 benefits and allowances
• child maintenance
• employment and training
• investigating and prosecuting tax
credits offences
• private pensions policy and
• 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 find 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
visit www.gov.uk/dwp/personal-information
charter
26 ESA50

What happens next
Please send back your completed questionnaire
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.
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 section
is important as it will help us make a quick
decision about your patient’s Employment
and Support Allowance claim.
This section concerns patients who are having,
waiting for or recovering from chemotherapy
or radiotherapy.
Please complete the rest of this section. If you
want more information about Employment
and Support Allowance, go to www.gov.uk/
employment-support-allowance
104 Details of cancer diagnosis
Include the type and site, stage
and any related diagnoses.
105 Details of treatment
Include the regime and
expected duration.
106 What stage are they at?
Awaiting or undergoing
chemotherapy or radiotherapy
Recovering (post completion of
treatment) from chemotherapy
or radiotherapy
107 In your opinion, is it likely that the
impact of the treatment has or will
have work-limiting side effects?
No
Yes
In your opinion, are these side
effects likely to limit all work?
No
Yes
In your opinion, how long
would you expect these side
effects to last?
27 ESA50

Your details
108 Name
109 Job title and qualifications
110 Signature
Please sign the form here after printing
111 Surgery stamp, hospital stamp or
address details
112 Date
DD/MM/YYYY
28 ESA50