To receive the right support, we need to know if your
health affects you at work or prevents you from
working.
Please answer honestly. We’ll need to check what you tell us about
your health.
Universal Credit (Test Portal)
Please complete all sections of the form before proceeding.
To receive the right support, we need to know if your
health affects you at work or prevents you from
working.
Please answer honestly. We’ll need to check what you tell us about
your health.
Do you have a disability, illness or ongoing condition
that you’d like to tell us about?
Terminal illness
If you’re terminally ill, you can continue online or ask us to call
you.
Tell us about any disabilities, illnesses or ongoing conditions.
Name of condition
Add a condition
(on the government site, you will be able to add multiple conditions)
Does your condition restrict your ability to work
or look for work?
You need to get one from your doctor if you’re ill for more than 7 days.
It may also be called a ‘statement of fitness for work’.
Name of doctor or medical centre
Street
Town
Postcode
Telephone number
We may need to contact your doctor about the health conditions
you’ve told us about.
Is it OK for your doctor to tell us about your health
conditions?
You can change your mind later. If you do, we will not ask your doctor
to share any more information with us.
If you say ‘No’, we may not have all the information we need when
we make a decision about your claim.
To give you the right support, there are a few more things we need to know about your health.
If you’re pregnant, does your health put you or your unborn child at
risk?
DD MM YYYY
Have you been diagnosed with a terminal illness?
What is your prognosis?
Are you currently in or expecting to go into hospital for more than
24 hours?
This includes residential rehabilitation.
Admission date
DD MM YYYY
Do you know what your discharge date is?
DD MM YYYY
Are you recovering from, receiving or expecting to receive any
medical treatments?
What treatment are you receiving?
Treatment 1 start date (if known)
DD MM YYYY
(on the government site, you will be able to add multiple treatments)
Tell us if you need any special support to help you at work.
I need other support (optional).
If your ability to work or look for work is still restricted after the end
date on your fit note, you will need to provide a new one.
If we don’t receive an up-to-date fit note, we will assume that you are
able to work.
If you are unable to work for more than 4 weeks, you will need to
provide more details and may need to attend an assessment.
From which date have you been unable to work?
DD MM YYYY
If you are ill for more than 7 days and you want to claim, you need a fit
note from your doctor.
If you are unable to work or look for work after seven days, you will
need a fit note from your doctor.
If we don’t receive an up-to-date fit note, we will assume that you are
able to work.
If you are unable to work for more than 4 weeks, you will need to
provide more details and may need to attend an assessment.
This practice task is now complete