Work Capability Assessment - Evidence letter
Sample Evidence letter
Request for evidence to support your claim
[Day] [Month] [Year]
[Name of professional]
[Address of professional]
Re: [Your name]
Address: [Your address]
D.o.B: [Your date of birth]
I am currently making a claim for Employment Support Allowance (ESA)/Universal Credit [delete as appropriate]as I am unfit for work/am being transferred over to ESA from another benefit [delete as appropriate].
It has been established that evidence from medical professionals involved with the diagnosis, care and treatment of a patient can be extremely useful in helping decision makers at the Department for Work and Pensions (DWP) to make decisions. Evidence from medical professionals can also help a decision to be made at the initial claim stage and could eliminate the stress of having to go through an appeal or medical assessment. It is important that this evidence is not just a list my diagnoses but shows how my illness affects my ability to do things.
I would be very grateful therefore if you could fill in this form and send it back to me. Please be aware that I am not in a position to pay for any report or information.
Rethink Mental illness have provided these documents. The information contained therefore focuses on mental rather than physical health needs. If there is information regarding my physical health needs in addition to my mental needs that you think is relevant, then please include this at the end of the form. I would be grateful for any information that you could provide.
- Please state what conditions I suffer from and what medications and treatments have been prescribed.
- How is my ability to learn simple tasks (e.g. setting an alarm clock or operating a washing machine) affected by my medical condition(s) or any treatment I am receiving for my medical condition(s)?
- How is my awareness of everyday hazards, e.g. Boiling water or sharp objects, affected by my medical condition(s) or any treatment I am receiving for my conditions(s)? Does this pose a significant risk to my safety or other’s?
- How is my ability to initiate and complete personal tasks affected by my medical condition(s) or any medication I am taking?
- How is my ability to initiate and cope with change affected by my medical conditions? Does this affect my ability to manage my day to day life?
- How is my ability to get to places affected by my medical conditions? Do I need supervision to get to familiar or unfamiliar places?
- How is my ability to cope with social engagement affected by my medical conditions? Am I caused distress by social engagement and does this preclude social engagement?
- How is my behaviour, when considering the appropriateness of the behaviour, affected by my medical conditions? Do I show signs of aggressive, uncontrolled or disinhibited behaviour? And would this be unreasonable in a workplace?
- If I am required to attend work focused interviews or work programmes. Would this have a detrimental affect on my health? If yes, how would I be affected?
- Is there any other information that you think is relevant?
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