» ESA Submission: Hypertension, Hypercholesterolaemia, Bilateral Sensorineural Hearing Loss, Osteoarthritis.

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Have you previously made a flexible working requests? Describe below

EXAMPLE 1: I have not made any previous flexible working requests. EXAMPLE 2: I have previously made a flexible working request on 1st January.

What is your working pattern and role?

Example: My current working pattern and role is 5 days a week as an office admin assistant.

Give details of the change you would like to make to your working pattern.

EXAMPLE: I would like to reduce my work hours from 35 to 30 per week.

When would you like this change to come into effect?

How can you employer deal with any effects the change could have?

EXAMPLE 1: I suggest sharing my job with another employee. EXAMPLE 2: I suggest that I could be being available to answer calls in emergencies.

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Give details of how your health impacts work. Or how your work impacts your health. You do not need to disclose your mental health problem if you do not want to.

Example: I've been diagnosed with anxiety and I'm receiving treatment for my mental health condition. I'm finding it difficult to concentrate at the moment and I'm concerned that without changes to my work I might have an accident.

What is your working pattern and role?

Example: My current working pattern and role is 5 days a week as an office admin assistant.

Provide details of the reasonable adjustments you would find helpful and why.

EXAMPLE: a later start time so that I can miss the rush hour because I'm finding it difficult to be around lots of people

How would this adjustment benefit your employer?

EXAMPLE: This would meant that I can arrive calm and clear headed ready for work.

Please suggest how you and your employer could deal with any effects of the changes.

EXAMPLE: I would like to suggest working later into the evening to make up for the time lost .

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What Is Your Relationship To This Person?

List Their Conditions Or Disabilities

What Are The Main Areas Where They Need Care

Describe The Main Difficulties You Have

What Is Your Name.

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N.I Number

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Please Detail The Medial Evidence That You Are Including

Covering Letter For GP in Seeking Home Assessment ESA or PIP.

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DLA Template Diary

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Migraine Reasonable Adjustments Request Template

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Who is your employer?

Employer's Address

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How many days off have you taken?

Please describe the symptoms of you condition.

What adjustments would you like to be considered?

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Repaying Debt To Your Energy Supplier

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Type of supply:

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How Much Do You Currently Pay Back Per Week? (£)

Per Week, How Much Would You Like To Pay Back? (£)

Please Provide The Supplier Some Information About Your Situation. Please see example.

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Challenging Your PIP Decision

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Healthcare Professional Information Request

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Please Select Your Claim Type

Why Are You Making This Claim?

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ESA Submission: Hypertension, Hypercholesterolaemia, Bilateral Sensorineural Hearing Loss, Osteoarthritis.

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