Fill in this form if you are making a claim for benefits or National Insurance credits on the basis of a limited capacity for work.
You need to fill in this form if you’re asked to do a Work Capability Assessment for claiming Employment Support Allowance (ESA).
This form asks about your physical and mental health. You need to answer all questions.
You need to save this form and open it in Adobe Acrobat Reader 8.1.2 otherwise it won’t work.
If you have any questions about the form, please contact the office that asked you to fill it in.
Residents of Northern Ireland
This form should not be used by residents of Northern Ireland who should contact the Employment and Support Allowance Centre.