form_id stringclasses 71
values | document_type stringclasses 2
values | section stringclasses 457
values | question_number stringclasses 729
values | question_sub_type stringclasses 3
values | question_text stringlengths 2 1.77k ⌀ | input_type stringclasses 8
values | tick_options listlengths 0 16 ⌀ | guidance_notes stringclasses 562
values | evidence_required bool 2
classes | declaration_required bool 2
classes | general_instructions stringclasses 79
values |
|---|---|---|---|---|---|---|---|---|---|---|---|
SSP1 | form | If you are an employer section (Employer to complete) | Q1 | standard | Please tick one of the following boxes | tick_box | [
"I have enclosed medical information that covers a period I cannot pay SSP",
"I have not enclosed medical information"
] | If you are an employer, please tick one of the following boxes. When you have completed this form, you must give it to the employee. For more information about SSP go to www.gov.uk/employers-sick-pay. Or you can contact HM Revenue and Customs Employer helpline on 0300 200 3200. | false | true | Please complete If you are an employer, or if you are an employee. This medical information should state whether or not the employee is not fit for work or may be fit for work. Return medical information to your employee as they may need it for future benefit applications. If you are an employer, you can ask your emplo... |
SSP1 | form | If you are an employer section (Employer to complete) | Q2 | standard | I declare that the information I have given on this form is correct and complete as far as I know and believe. | signature | [] | I understand that if this employee has been getting SSP, I must continue to pay SSP up to and including the day before the date I have written in the About your employee section of this form. | false | true | Please complete If you are an employer, or if you are an employee. This medical information should state whether or not the employee is not fit for work or may be fit for work. Return medical information to your employee as they may need it for future benefit applications. If you are an employer, you can ask your emplo... |
SSP1 | form | If you are an employer section (Employer to complete) | Q3 | standard | 01 Employer’s name | open_text | [] | false | true | Please complete If you are an employer, or if you are an employee. This medical information should state whether or not the employee is not fit for work or may be fit for work. Return medical information to your employee as they may need it for future benefit applications. If you are an employer, you can ask your emplo... | |
SSP1 | form | If you are an employer section (Employer to complete) | Q4 | standard | 02 Employer’s signature | signature | [] | false | true | Please complete If you are an employer, or if you are an employee. This medical information should state whether or not the employee is not fit for work or may be fit for work. Return medical information to your employee as they may need it for future benefit applications. If you are an employer, you can ask your emplo... | |
SSP1 | form | If you are an employer section (Employer to complete) | Q5 | standard | 03 Date | date | [] | false | true | Please complete If you are an employer, or if you are an employee. This medical information should state whether or not the employee is not fit for work or may be fit for work. Return medical information to your employee as they may need it for future benefit applications. If you are an employer, you can ask your emplo... | |
SSP1 | form | If you are an employer section (Employer to complete) | Q6 | standard | 04 Position in firm | open_text | [] | false | true | Please complete If you are an employer, or if you are an employee. This medical information should state whether or not the employee is not fit for work or may be fit for work. Return medical information to your employee as they may need it for future benefit applications. If you are an employer, you can ask your emplo... | |
SSP1 | form | If you are an employer section (Employer to complete) | Q7 | standard | 05 Phone number | open_text | [] | false | true | Please complete If you are an employer, or if you are an employee. This medical information should state whether or not the employee is not fit for work or may be fit for work. Return medical information to your employee as they may need it for future benefit applications. If you are an employer, you can ask your emplo... | |
SSP1 | form | If you are an employer section (Employer to complete) | Q8 | standard | 06 Fax number | open_text | [] | false | true | Please complete If you are an employer, or if you are an employee. This medical information should state whether or not the employee is not fit for work or may be fit for work. Return medical information to your employee as they may need it for future benefit applications. If you are an employer, you can ask your emplo... | |
SSP1 | form | If you are an employer section (Employer to complete) | Q9 | standard | 07 Email address | open_text | [] | false | true | Please complete If you are an employer, or if you are an employee. This medical information should state whether or not the employee is not fit for work or may be fit for work. Return medical information to your employee as they may need it for future benefit applications. If you are an employer, you can ask your emplo... | |
SSP1 | form | If you are an employer section (Employer to complete) | Q10 | standard | 08 Employer’s address | open_text | [] | false | true | Please complete If you are an employer, or if you are an employee. This medical information should state whether or not the employee is not fit for work or may be fit for work. Return medical information to your employee as they may need it for future benefit applications. If you are an employer, you can ask your emplo... | |
SSP1 | form | If you are an employer section (Employer to complete) | Q11 | standard | 09 Employer’s stamp | signature | [] | false | true | Please complete If you are an employer, or if you are an employee. This medical information should state whether or not the employee is not fit for work or may be fit for work. Return medical information to your employee as they may need it for future benefit applications. If you are an employer, you can ask your emplo... | |
SSP1 | form | About your employee (Employer to complete) | Q12 | standard | 10 Title | open_text | [] | For example Mr, Mrs, Miss, Ms or other | false | true | Please complete If you are an employer, or if you are an employee. This medical information should state whether or not the employee is not fit for work or may be fit for work. Return medical information to your employee as they may need it for future benefit applications. If you are an employer, you can ask your emplo... |
SSP1 | form | About your employee (Employer to complete) | Q13 | standard | 11 Surname or family name | open_text | [] | false | true | Please complete If you are an employer, or if you are an employee. This medical information should state whether or not the employee is not fit for work or may be fit for work. Return medical information to your employee as they may need it for future benefit applications. If you are an employer, you can ask your emplo... | |
SSP1 | form | About your employee (Employer to complete) | Q14 | standard | 12 All other names, in full | open_text | [] | false | true | Please complete If you are an employer, or if you are an employee. This medical information should state whether or not the employee is not fit for work or may be fit for work. Return medical information to your employee as they may need it for future benefit applications. If you are an employer, you can ask your emplo... | |
SSP1 | form | About your employee (Employer to complete) | Q15 | standard | 13 Address | open_text | [] | false | true | Please complete If you are an employer, or if you are an employee. This medical information should state whether or not the employee is not fit for work or may be fit for work. Return medical information to your employee as they may need it for future benefit applications. If you are an employer, you can ask your emplo... | |
SSP1 | form | About your employee (Employer to complete) | Q16 | standard | Postcode | open_text | [] | false | true | Please complete If you are an employer, or if you are an employee. This medical information should state whether or not the employee is not fit for work or may be fit for work. Return medical information to your employee as they may need it for future benefit applications. If you are an employer, you can ask your emplo... | |
SSP1 | form | About your employee (Employer to complete) | Q17 | standard | 14 National Insurance (NI) number | open_text | [] | false | true | Please complete If you are an employer, or if you are an employee. This medical information should state whether or not the employee is not fit for work or may be fit for work. Return medical information to your employee as they may need it for future benefit applications. If you are an employer, you can ask your emplo... | |
SSP1 | form | About your employee (Employer to complete) | Q18 | standard | 15 Clock, payroll or employee number | open_text | [] | false | true | Please complete If you are an employer, or if you are an employee. This medical information should state whether or not the employee is not fit for work or may be fit for work. Return medical information to your employee as they may need it for future benefit applications. If you are an employer, you can ask your emplo... | |
SSP1 | form | About your employee (Employer to complete) | Q19 | standard | 16 Tax reference number | open_text | [] | This is also known as the Employee PAYE reference. | false | true | Please complete If you are an employer, or if you are an employee. This medical information should state whether or not the employee is not fit for work or may be fit for work. Return medical information to your employee as they may need it for future benefit applications. If you are an employer, you can ask your emplo... |
SSP1 | form | About your employee (Employer to complete) | Q20 | standard | 17 Have you been paying your employee SSP? | tick_box | [
"No",
"Yes"
] | Please tell us the start and end dates of the payment. From To If payment has not ended yet, please tell us the date when it will end. | false | true | Please complete If you are an employer, or if you are an employee. This medical information should state whether or not the employee is not fit for work or may be fit for work. Return medical information to your employee as they may need it for future benefit applications. If you are an employer, you can ask your emplo... |
SSP1 | form | About your employee (Employer to complete) | Q21 | standard | From | date | [] | false | true | Please complete If you are an employer, or if you are an employee. This medical information should state whether or not the employee is not fit for work or may be fit for work. Return medical information to your employee as they may need it for future benefit applications. If you are an employer, you can ask your emplo... | |
SSP1 | form | About your employee (Employer to complete) | Q22 | standard | To | date | [] | false | true | Please complete If you are an employer, or if you are an employee. This medical information should state whether or not the employee is not fit for work or may be fit for work. Return medical information to your employee as they may need it for future benefit applications. If you are an employer, you can ask your emplo... | |
SSP1 | form | About your employee (Employer to complete) | Q23 | standard | If payment has not ended yet, please tell us the date when it will end. | date | [] | false | true | Please complete If you are an employer, or if you are an employee. This medical information should state whether or not the employee is not fit for work or may be fit for work. Return medical information to your employee as they may need it for future benefit applications. If you are an employer, you can ask your emplo... | |
SSP1 | form | Why you cannot get Statutory Sick Pay (Employer to complete) | Q24 | standard | You cannot get SSP on or after this date | date | [] | This is because: You got Employment and Support Allowance during the last 12 weeks. Your contract of employment has ended or were coming to an end. You became sick after your contract of employment ended. You were away from work because of a trade dispute which started before the first day you were sick. (Note for empl... | false | true | Please complete If you are an employer, or if you are an employee. This medical information should state whether or not the employee is not fit for work or may be fit for work. Return medical information to your employee as they may need it for future benefit applications. If you are an employer, you can ask your emplo... |
SSP1 | form | If you are an employer section (Employer to complete) | Q1 | standard | Please tick one of the following boxes | tick_box | [
"I have enclosed medical information that covers a period I cannot pay SSP",
"I have not enclosed medical information"
] | If you are an employer, please tick one of the following boxes. When you have completed this form, you must give it to the employee. For more information about SSP go to www.gov.uk/employers-sick-pay. Or you can contact HM Revenue and Customs Employer helpline on 0300 200 3200. | false | true | Please complete If you are an employer, or if you are an employee. This medical information should state whether or not the employee is not fit for work or may be fit for work. Return medical information to your employee as they may need it for future benefit applications. |
SSP1 | form | If you are an employer section (Employer to complete) | Q2 | standard | I declare that the information I have given on this form is correct and complete as far as I know and believe. | signature | [] | I understand that if this employee has been getting SSP, I must continue to pay SSP up to and including the day before the date I have written in the About your employee section of this form. | false | true | Please complete If you are an employer, or if you are an employee. This medical information should state whether or not the employee is not fit for work or may be fit for work. Return medical information to your employee as they may need it for future benefit applications. |
SSP1 | form | If you are an employer section (Employer to complete) | Q3 | standard | 01 Employer’s name | open_text | [] | false | true | Please complete If you are an employer, or if you are an employee. This medical information should state whether or not the employee is not fit for work or may be fit for work. Return medical information to your employee as they may need it for future benefit applications. | |
SSP1 | form | If you are an employer section (Employer to complete) | Q4 | standard | 02 Employer’s signature | signature | [] | false | true | Please complete If you are an employer, or if you are an employee. This medical information should state whether or not the employee is not fit for work or may be fit for work. Return medical information to your employee as they may need it for future benefit applications. | |
SSP1 | form | If you are an employer section (Employer to complete) | Q5 | standard | 03 Date | date | [] | false | true | Please complete If you are an employer, or if you are an employee. This medical information should state whether or not the employee is not fit for work or may be fit for work. Return medical information to your employee as they may need it for future benefit applications. | |
SSP1 | form | If you are an employer section (Employer to complete) | Q6 | standard | 04 Position in firm | open_text | [] | false | true | Please complete If you are an employer, or if you are an employee. This medical information should state whether or not the employee is not fit for work or may be fit for work. Return medical information to your employee as they may need it for future benefit applications. | |
SSP1 | form | If you are an employer section (Employer to complete) | Q7 | standard | 05 Phone number | open_text | [] | false | true | Please complete If you are an employer, or if you are an employee. This medical information should state whether or not the employee is not fit for work or may be fit for work. Return medical information to your employee as they may need it for future benefit applications. | |
SSP1 | form | If you are an employer section (Employer to complete) | Q8 | standard | 06 Fax number | open_text | [] | false | true | Please complete If you are an employer, or if you are an employee. This medical information should state whether or not the employee is not fit for work or may be fit for work. Return medical information to your employee as they may need it for future benefit applications. | |
SSP1 | form | If you are an employer section (Employer to complete) | Q9 | standard | 07 Email address | open_text | [] | false | true | Please complete If you are an employer, or if you are an employee. This medical information should state whether or not the employee is not fit for work or may be fit for work. Return medical information to your employee as they may need it for future benefit applications. | |
SSP1 | form | If you are an employer section (Employer to complete) | Q10 | standard | 08 Employer’s address | open_text | [] | false | true | Please complete If you are an employer, or if you are an employee. This medical information should state whether or not the employee is not fit for work or may be fit for work. Return medical information to your employee as they may need it for future benefit applications. | |
SSP1 | form | If you are an employer section (Employer to complete) | Q11 | standard | 09 Employer’s stamp | signature | [] | false | true | Please complete If you are an employer, or if you are an employee. This medical information should state whether or not the employee is not fit for work or may be fit for work. Return medical information to your employee as they may need it for future benefit applications. | |
SSP1 | form | About your employee (Employer to complete) | Q12 | standard | 10 Title | open_text | [] | For example Mr, Mrs, Miss, Ms or other | false | true | Please complete If you are an employer, or if you are an employee. This medical information should state whether or not the employee is not fit for work or may be fit for work. Return medical information to your employee as they may need it for future benefit applications. |
SSP1 | form | About your employee (Employer to complete) | Q13 | standard | 11 Surname or family name | open_text | [] | false | true | Please complete If you are an employer, or if you are an employee. This medical information should state whether or not the employee is not fit for work or may be fit for work. Return medical information to your employee as they may need it for future benefit applications. | |
SSP1 | form | About your employee (Employer to complete) | Q14 | standard | 12 All other names, in full | open_text | [] | false | true | Please complete If you are an employer, or if you are an employee. This medical information should state whether or not the employee is not fit for work or may be fit for work. Return medical information to your employee as they may need it for future benefit applications. | |
SSP1 | form | About your employee (Employer to complete) | Q15 | standard | 13 Address | open_text | [] | false | true | Please complete If you are an employer, or if you are an employee. This medical information should state whether or not the employee is not fit for work or may be fit for work. Return medical information to your employee as they may need it for future benefit applications. | |
SSP1 | form | About your employee (Employer to complete) | Q16 | standard | 14 National Insurance (NI) number | open_text | [] | false | true | Please complete If you are an employer, or if you are an employee. This medical information should state whether or not the employee is not fit for work or may be fit for work. Return medical information to your employee as they may need it for future benefit applications. | |
SSP1 | form | About your employee (Employer to complete) | Q17 | standard | 15 Clock, payroll or employee number | open_text | [] | false | true | Please complete If you are an employer, or if you are an employee. This medical information should state whether or not the employee is not fit for work or may be fit for work. Return medical information to your employee as they may need it for future benefit applications. | |
SSP1 | form | About your employee (Employer to complete) | Q18 | standard | 16 Tax reference number | open_text | [] | This is also known as the Employee PAYE reference. | false | true | Please complete If you are an employer, or if you are an employee. This medical information should state whether or not the employee is not fit for work or may be fit for work. Return medical information to your employee as they may need it for future benefit applications. |
SSP1 | form | About your employee (Employer to complete) | Q19 | standard | 17 Have you been paying your employee SSP? | tick_box | [
"Yes",
"No"
] | Please tell us the start and end dates of the payment. From To If payment has not ended yet, please tell us the date when it will end. | false | true | Please complete If you are an employer, or if you are an employee. This medical information should state whether or not the employee is not fit for work or may be fit for work. Return medical information to your employee as they may need it for future benefit applications. |
SSP1 | form | About your employee (Employer to complete) | Q20 | standard | From | date | [] | false | true | Please complete If you are an employer, or if you are an employee. This medical information should state whether or not the employee is not fit for work or may be fit for work. Return medical information to your employee as they may need it for future benefit applications. | |
SSP1 | form | About your employee (Employer to complete) | Q21 | standard | To | date | [] | false | true | Please complete If you are an employer, or if you are an employee. This medical information should state whether or not the employee is not fit for work or may be fit for work. Return medical information to your employee as they may need it for future benefit applications. | |
SSP1 | form | About your employee (Employer to complete) | Q22 | standard | Postcode | open_text | [] | false | true | Please complete If you are an employer, or if you are an employee. This medical information should state whether or not the employee is not fit for work or may be fit for work. Return medical information to your employee as they may need it for future benefit applications. | |
SSP1 | form | Why you cannot get Statutory Sick Pay (Employer to complete) | Q23 | standard | Why you cannot get Statutory Sick Pay | open_text | [] | You cannot get SSP on or after this date. This is because: You got Employment and Support Allowance during the last 12 weeks. Your contract of employment has ended or were coming to an end. You became sick after your contract of employment ended. You were away from work because of a trade dispute which started before t... | false | true | Please complete If you are an employer, or if you are an employee. This medical information should state whether or not the employee is not fit for work or may be fit for work. Return medical information to your employee as they may need it for future benefit applications. |
SSP1 | form | Employee - what to do now | Q24 | standard | Employee - what to do now | open_text | [] | If you disagree with your employer’s decision not to pay you SSP, ask your employer to explain it to you. If, after talking to your employer, you are still unsure about this decision you can visit www.gov.uk/statutory-sick-pay for more information. Ask your employer for a reason if you think: • their decision not to pa... | false | true | Please complete If you are an employer, or if you are an employee. This medical information should state whether or not the employee is not fit for work or may be fit for work. Return medical information to your employee as they may need it for future benefit applications. |
BI100A | form | Part 1: About you | Q1 | standard | Title | open_text | [] | For example, Mr, Ms, Mrs, Miss or other. | false | true | Answer all the questions that apply to you and your partner, if you have one. If you are filling this form in with a pen, write in black ink and use CAPITAL LETTERS. Please make sure that you complete the Consent in Part 2 and sign the Declaration in Part 12. If you do not fill this in, we will contact you and it may d... |
BI100A | form | Part 1: About you | Q2 | standard | Surname or family name | open_text | [] | false | true | Answer all the questions that apply to you and your partner, if you have one. If you are filling this form in with a pen, write in black ink and use CAPITAL LETTERS. Please make sure that you complete the Consent in Part 2 and sign the Declaration in Part 12. If you do not fill this in, we will contact you and it may d... | |
BI100A | form | Part 1: About you | Q3 | standard | All other names | open_text | [] | In full. | false | true | Answer all the questions that apply to you and your partner, if you have one. If you are filling this form in with a pen, write in black ink and use CAPITAL LETTERS. Please make sure that you complete the Consent in Part 2 and sign the Declaration in Part 12. If you do not fill this in, we will contact you and it may d... |
BI100A | form | Part 1: About you | Q4 | standard | Any other surnames you have been known by or are using now | open_text | [] | Please include maiden name, all former married names and all changes of family name. | false | true | Answer all the questions that apply to you and your partner, if you have one. If you are filling this form in with a pen, write in black ink and use CAPITAL LETTERS. Please make sure that you complete the Consent in Part 2 and sign the Declaration in Part 12. If you do not fill this in, we will contact you and it may d... |
BI100A | form | Part 1: About you | Q5 | standard | Address | open_text | [] | false | true | Answer all the questions that apply to you and your partner, if you have one. If you are filling this form in with a pen, write in black ink and use CAPITAL LETTERS. Please make sure that you complete the Consent in Part 2 and sign the Declaration in Part 12. If you do not fill this in, we will contact you and it may d... | |
BI100A | form | Part 1: About you | Q6 | standard | Mobile phone number | open_text | [] | false | true | Answer all the questions that apply to you and your partner, if you have one. If you are filling this form in with a pen, write in black ink and use CAPITAL LETTERS. Please make sure that you complete the Consent in Part 2 and sign the Declaration in Part 12. If you do not fill this in, we will contact you and it may d... | |
BI100A | form | Part 1: About you | Q7 | standard | Daytime phone number | open_text | [] | If you have one. | false | true | Answer all the questions that apply to you and your partner, if you have one. If you are filling this form in with a pen, write in black ink and use CAPITAL LETTERS. Please make sure that you complete the Consent in Part 2 and sign the Declaration in Part 12. If you do not fill this in, we will contact you and it may d... |
BI100A | form | Part 1: About you | Q8 | standard | Email address | open_text | [] | false | true | Answer all the questions that apply to you and your partner, if you have one. If you are filling this form in with a pen, write in black ink and use CAPITAL LETTERS. Please make sure that you complete the Consent in Part 2 and sign the Declaration in Part 12. If you do not fill this in, we will contact you and it may d... | |
BI100A | form | Part 1: About you | Q9 | standard | Date of birth | date | [] | DD/MM/YYYY | false | true | Answer all the questions that apply to you and your partner, if you have one. If you are filling this form in with a pen, write in black ink and use CAPITAL LETTERS. Please make sure that you complete the Consent in Part 2 and sign the Declaration in Part 12. If you do not fill this in, we will contact you and it may d... |
BI100A | form | Part 1: About you | Q10 | standard | National Insurance (N I) number | open_text | [] | You can find the number on your National Insurance (N I) numbercard, letters about your benefit or wage slips. | false | true | Answer all the questions that apply to you and your partner, if you have one. If you are filling this form in with a pen, write in black ink and use CAPITAL LETTERS. Please make sure that you complete the Consent in Part 2 and sign the Declaration in Part 12. If you do not fill this in, we will contact you and it may d... |
BI100A | form | Part 1: About you | Q11 | standard | If you do not know your N I number, have you ever had one or used one at any time? | tick_box | [
"No",
"Yes"
] | false | true | Answer all the questions that apply to you and your partner, if you have one. If you are filling this form in with a pen, write in black ink and use CAPITAL LETTERS. Please make sure that you complete the Consent in Part 2 and sign the Declaration in Part 12. If you do not fill this in, we will contact you and it may d... | |
BI100A | form | Part 1: About you | Q12 | standard | Your partner’s title | open_text | [] | For example, Mr, Ms, Mrs, Miss or other. | false | true | Answer all the questions that apply to you and your partner, if you have one. If you are filling this form in with a pen, write in black ink and use CAPITAL LETTERS. Please make sure that you complete the Consent in Part 2 and sign the Declaration in Part 12. If you do not fill this in, we will contact you and it may d... |
BI100A | form | Part 1: About you | Q13 | standard | Your partner’s surname or family name | open_text | [] | false | true | Answer all the questions that apply to you and your partner, if you have one. If you are filling this form in with a pen, write in black ink and use CAPITAL LETTERS. Please make sure that you complete the Consent in Part 2 and sign the Declaration in Part 12. If you do not fill this in, we will contact you and it may d... | |
BI100A | form | Part 1: About you | Q14 | standard | All of your partner’s other names | open_text | [] | In full. | false | true | Answer all the questions that apply to you and your partner, if you have one. If you are filling this form in with a pen, write in black ink and use CAPITAL LETTERS. Please make sure that you complete the Consent in Part 2 and sign the Declaration in Part 12. If you do not fill this in, we will contact you and it may d... |
BI100A | form | Part 1: About you | Q15 | standard | Your partner’s address | open_text | [] | false | true | Answer all the questions that apply to you and your partner, if you have one. If you are filling this form in with a pen, write in black ink and use CAPITAL LETTERS. Please make sure that you complete the Consent in Part 2 and sign the Declaration in Part 12. If you do not fill this in, we will contact you and it may d... | |
BI100A | form | Part 1: About you | Q16 | standard | Your partner’s date of birth | date | [] | DD/MM/YYYY | false | true | Answer all the questions that apply to you and your partner, if you have one. If you are filling this form in with a pen, write in black ink and use CAPITAL LETTERS. Please make sure that you complete the Consent in Part 2 and sign the Declaration in Part 12. If you do not fill this in, we will contact you and it may d... |
BI100A | form | Part 1: About you | Q17 | standard | Your partner’s National Insurance (N I) number | open_text | [] | You can find the number on your National Insurance (N I) numbercard, letters about your benefit or wage slips. | false | true | Answer all the questions that apply to you and your partner, if you have one. If you are filling this form in with a pen, write in black ink and use CAPITAL LETTERS. Please make sure that you complete the Consent in Part 2 and sign the Declaration in Part 12. If you do not fill this in, we will contact you and it may d... |
BI100A | form | Part 2: Consent | Q18 | standard | Do you give consent for your doctor or other relevant professionals to give DWP more information about your health condition? | tick_box | [
"No, information about my health cannot be shared with DWP or the health care professionals that work for them.",
"Yes, information about my health can be shared with DWP or the health care professionals that work for them."
] | false | true | Answer all the questions that apply to you and your partner, if you have one. If you are filling this form in with a pen, write in black ink and use CAPITAL LETTERS. Please make sure that you complete the Consent in Part 2 and sign the Declaration in Part 12. If you do not fill this in, we will contact you and it may d... | |
BI100A | form | Part 3: Filling in the form and signing it for someone else | Q19 | standard | Please tell us why the claimant cannot fill in the form themselves | open_text | [] | Only complete this section if you are filling in the form for the claimant because they cannot do so or they have died. | false | true | Answer all the questions that apply to you and your partner, if you have one. If you are filling this form in with a pen, write in black ink and use CAPITAL LETTERS. Please make sure that you complete the Consent in Part 2 and sign the Declaration in Part 12. If you do not fill this in, we will contact you and it may d... |
BI100A | form | Part 3: Filling in the form and signing it for someone else | Q20 | standard | If the person has died, please tell us when this happened | date | [] | DD/MM/YYYY | false | true | Answer all the questions that apply to you and your partner, if you have one. If you are filling this form in with a pen, write in black ink and use CAPITAL LETTERS. Please make sure that you complete the Consent in Part 2 and sign the Declaration in Part 12. If you do not fill this in, we will contact you and it may d... |
BI100A | form | Part 3: Filling in the form and signing it for someone else | Q21 | standard | Title | open_text | [] | For example, Mr, Ms, Mrs, Miss or other. | false | true | Answer all the questions that apply to you and your partner, if you have one. If you are filling this form in with a pen, write in black ink and use CAPITAL LETTERS. Please make sure that you complete the Consent in Part 2 and sign the Declaration in Part 12. If you do not fill this in, we will contact you and it may d... |
BI100A | form | Part 3: Filling in the form and signing it for someone else | Q22 | standard | Surname or family name | open_text | [] | false | true | Answer all the questions that apply to you and your partner, if you have one. If you are filling this form in with a pen, write in black ink and use CAPITAL LETTERS. Please make sure that you complete the Consent in Part 2 and sign the Declaration in Part 12. If you do not fill this in, we will contact you and it may d... | |
BI100A | form | Part 3: Filling in the form and signing it for someone else | Q23 | standard | All other names | open_text | [] | In full. | false | true | Answer all the questions that apply to you and your partner, if you have one. If you are filling this form in with a pen, write in black ink and use CAPITAL LETTERS. Please make sure that you complete the Consent in Part 2 and sign the Declaration in Part 12. If you do not fill this in, we will contact you and it may d... |
BI100A | form | Part 3: Filling in the form and signing it for someone else | Q24 | standard | What is your relationship to the claimant? | open_text | [] | false | true | Answer all the questions that apply to you and your partner, if you have one. If you are filling this form in with a pen, write in black ink and use CAPITAL LETTERS. Please make sure that you complete the Consent in Part 2 and sign the Declaration in Part 12. If you do not fill this in, we will contact you and it may d... | |
BI100A | form | Part 3: Filling in the form and signing it for someone else | Q25 | standard | Address | open_text | [] | false | true | Answer all the questions that apply to you and your partner, if you have one. If you are filling this form in with a pen, write in black ink and use CAPITAL LETTERS. Please make sure that you complete the Consent in Part 2 and sign the Declaration in Part 12. If you do not fill this in, we will contact you and it may d... | |
BI100A | form | Part 3: Filling in the form and signing it for someone else | Q26 | standard | Your mobile phone number | open_text | [] | false | true | Answer all the questions that apply to you and your partner, if you have one. If you are filling this form in with a pen, write in black ink and use CAPITAL LETTERS. Please make sure that you complete the Consent in Part 2 and sign the Declaration in Part 12. If you do not fill this in, we will contact you and it may d... | |
BI100A | form | Part 3: Filling in the form and signing it for someone else | Q27 | standard | Your daytime phone number | open_text | [] | If you have one. | false | true | Answer all the questions that apply to you and your partner, if you have one. If you are filling this form in with a pen, write in black ink and use CAPITAL LETTERS. Please make sure that you complete the Consent in Part 2 and sign the Declaration in Part 12. If you do not fill this in, we will contact you and it may d... |
BI100A | form | Part 3: Filling in the form and signing it for someone else | Q28 | standard | Your email address | open_text | [] | false | true | Answer all the questions that apply to you and your partner, if you have one. If you are filling this form in with a pen, write in black ink and use CAPITAL LETTERS. Please make sure that you complete the Consent in Part 2 and sign the Declaration in Part 12. If you do not fill this in, we will contact you and it may d... | |
BI100A | form | Part 3: Filling in the form and signing it for someone else | Q29 | standard | Date of birth | date | [] | DD/MM/YYYY | false | true | Answer all the questions that apply to you and your partner, if you have one. If you are filling this form in with a pen, write in black ink and use CAPITAL LETTERS. Please make sure that you complete the Consent in Part 2 and sign the Declaration in Part 12. If you do not fill this in, we will contact you and it may d... |
BI100A | form | Part 3: Filling in the form and signing it for someone else | Q30 | standard | National Insurance (N I) number | open_text | [] | You can find the number on your National Insurance (N I) numbercard, letters about your benefit or wage slips. | false | true | Answer all the questions that apply to you and your partner, if you have one. If you are filling this form in with a pen, write in black ink and use CAPITAL LETTERS. Please make sure that you complete the Consent in Part 2 and sign the Declaration in Part 12. If you do not fill this in, we will contact you and it may d... |
BI100A | form | Part 4: About your work or your approved employment training scheme or course | Q31 | standard | Name of the employer or training provider at the time of the accident | open_text | [] | For example, Jobcentre Plus or another organisation. | false | true | Answer all the questions that apply to you and your partner, if you have one. If you are filling this form in with a pen, write in black ink and use CAPITAL LETTERS. Please make sure that you complete the Consent in Part 2 and sign the Declaration in Part 12. If you do not fill this in, we will contact you and it may d... |
BI100A | form | Part 4: About your work or your approved employment training scheme or course | Q32 | standard | Employer’s or training provider’s address | open_text | [] | false | true | Answer all the questions that apply to you and your partner, if you have one. If you are filling this form in with a pen, write in black ink and use CAPITAL LETTERS. Please make sure that you complete the Consent in Part 2 and sign the Declaration in Part 12. If you do not fill this in, we will contact you and it may d... | |
BI100A | form | Part 4: About your work or your approved employment training scheme or course | Q33 | standard | If your employer or training provider has changed their name or address since your accident, please tell us the new details | open_text | [] | false | true | Answer all the questions that apply to you and your partner, if you have one. If you are filling this form in with a pen, write in black ink and use CAPITAL LETTERS. Please make sure that you complete the Consent in Part 2 and sign the Declaration in Part 12. If you do not fill this in, we will contact you and it may d... | |
BI100A | form | Part 4: About your work or your approved employment training scheme or course | Q34 | standard | In which business area is this company involved? | open_text | [] | false | true | Answer all the questions that apply to you and your partner, if you have one. If you are filling this form in with a pen, write in black ink and use CAPITAL LETTERS. Please make sure that you complete the Consent in Part 2 and sign the Declaration in Part 12. If you do not fill this in, we will contact you and it may d... | |
BI100A | form | Part 4: About your work or your approved employment training scheme or course | Q35 | standard | Is this employer or training provider still in business? | tick_box | [
"No",
"Yes"
] | false | true | Answer all the questions that apply to you and your partner, if you have one. If you are filling this form in with a pen, write in black ink and use CAPITAL LETTERS. Please make sure that you complete the Consent in Part 2 and sign the Declaration in Part 12. If you do not fill this in, we will contact you and it may d... | |
BI100A | form | Part 4: About your work or your approved employment training scheme or course | Q36 | standard | If you were on an approved employment training course, who sent you on it? | open_text | [] | false | true | Answer all the questions that apply to you and your partner, if you have one. If you are filling this form in with a pen, write in black ink and use CAPITAL LETTERS. Please make sure that you complete the Consent in Part 2 and sign the Declaration in Part 12. If you do not fill this in, we will contact you and it may d... | |
BI100A | form | Part 4: About your work or your approved employment training scheme or course | Q37 | standard | Were you employed by an agency? | tick_box | [
"No",
"Yes"
] | If you were employed by an agency please provide their name and address | false | true | Answer all the questions that apply to you and your partner, if you have one. If you are filling this form in with a pen, write in black ink and use CAPITAL LETTERS. Please make sure that you complete the Consent in Part 2 and sign the Declaration in Part 12. If you do not fill this in, we will contact you and it may d... |
BI100A | form | Part 4: About your work or your approved employment training scheme or course | Q38 | standard | Employer’s or training provider’s phone number | open_text | [] | false | true | Answer all the questions that apply to you and your partner, if you have one. If you are filling this form in with a pen, write in black ink and use CAPITAL LETTERS. Please make sure that you complete the Consent in Part 2 and sign the Declaration in Part 12. If you do not fill this in, we will contact you and it may d... | |
BI100A | form | Part 4: About your work or your approved employment training scheme or course | Q39 | standard | Employer’s or training provider’s email address | open_text | [] | false | true | Answer all the questions that apply to you and your partner, if you have one. If you are filling this form in with a pen, write in black ink and use CAPITAL LETTERS. Please make sure that you complete the Consent in Part 2 and sign the Declaration in Part 12. If you do not fill this in, we will contact you and it may d... | |
BI100A | form | Part 4: About your work or your approved employment training scheme or course | Q40 | standard | Workplace | open_text | [] | false | true | Answer all the questions that apply to you and your partner, if you have one. If you are filling this form in with a pen, write in black ink and use CAPITAL LETTERS. Please make sure that you complete the Consent in Part 2 and sign the Declaration in Part 12. If you do not fill this in, we will contact you and it may d... | |
BI100A | form | Part 4: About your work or your approved employment training scheme or course | Q41 | standard | When did you work there? | date | [] | This means when you actually went to work. If you were employed by the company but were off work sick, please enter the date when you last went to work. If you are not sure of the dates, give an approximate date. | false | true | Answer all the questions that apply to you and your partner, if you have one. If you are filling this form in with a pen, write in black ink and use CAPITAL LETTERS. Please make sure that you complete the Consent in Part 2 and sign the Declaration in Part 12. If you do not fill this in, we will contact you and it may d... |
BI100A | form | Part 4: About your work or your approved employment training scheme or course | Q42 | standard | Your job title | open_text | [] | false | true | Answer all the questions that apply to you and your partner, if you have one. If you are filling this form in with a pen, write in black ink and use CAPITAL LETTERS. Please make sure that you complete the Consent in Part 2 and sign the Declaration in Part 12. If you do not fill this in, we will contact you and it may d... | |
BI100A | form | Part 4: About your work or your approved employment training scheme or course | Q43 | standard | Payroll, staff or other reference number | open_text | [] | false | true | Answer all the questions that apply to you and your partner, if you have one. If you are filling this form in with a pen, write in black ink and use CAPITAL LETTERS. Please make sure that you complete the Consent in Part 2 and sign the Declaration in Part 12. If you do not fill this in, we will contact you and it may d... | |
BI100A | form | Part 4: About your work or your approved employment training scheme or course | Q44 | standard | If you were on a training course, what type of training course were you on? | open_text | [] | false | true | Answer all the questions that apply to you and your partner, if you have one. If you are filling this form in with a pen, write in black ink and use CAPITAL LETTERS. Please make sure that you complete the Consent in Part 2 and sign the Declaration in Part 12. If you do not fill this in, we will contact you and it may d... | |
BI100A | form | Part 5: About the accident | Q45 | standard | What date and time did the accident happen? | date | [] | Please send in your wage slip for this date. DD/MM/YYYY | false | true | Answer all the questions that apply to you and your partner, if you have one. If you are filling this form in with a pen, write in black ink and use CAPITAL LETTERS. Please make sure that you complete the Consent in Part 2 and sign the Declaration in Part 12. If you do not fill this in, we will contact you and it may d... |
BI100A | form | Part 5: About the accident | Q46 | standard | Where at work did the accident happen? | open_text | [] | Please tell us the exact place where it happened. | false | true | Answer all the questions that apply to you and your partner, if you have one. If you are filling this form in with a pen, write in black ink and use CAPITAL LETTERS. Please make sure that you complete the Consent in Part 2 and sign the Declaration in Part 12. If you do not fill this in, we will contact you and it may d... |
BI100A | form | Part 5: About the accident | Q47 | standard | Have you reported the accident to your employer or training provider? | tick_box | [
"No",
"Yes"
] | Please send us a copy of the accident report. Please tell them about the accident now. | false | true | Answer all the questions that apply to you and your partner, if you have one. If you are filling this form in with a pen, write in black ink and use CAPITAL LETTERS. Please make sure that you complete the Consent in Part 2 and sign the Declaration in Part 12. If you do not fill this in, we will contact you and it may d... |
BI100A | form | Part 5: About the accident | Q48 | standard | If you were employed by an agency did you report the accident to the agency? | tick_box | [
"No",
"Yes"
] | false | true | Answer all the questions that apply to you and your partner, if you have one. If you are filling this form in with a pen, write in black ink and use CAPITAL LETTERS. Please make sure that you complete the Consent in Part 2 and sign the Declaration in Part 12. If you do not fill this in, we will contact you and it may d... | |
BI100A | form | Part 5: About the accident | Q49 | standard | Have you ever claimed benefit under an Industrial Injuries Scheme for this accident in the past? | tick_box | [
"No",
"Yes"
] | Please tell us when. | false | true | Answer all the questions that apply to you and your partner, if you have one. If you are filling this form in with a pen, write in black ink and use CAPITAL LETTERS. Please make sure that you complete the Consent in Part 2 and sign the Declaration in Part 12. If you do not fill this in, we will contact you and it may d... |
BI100A | form | Part 5: About the accident | Q50 | standard | Have you ever contacted us about this accident? | tick_box | [
"No",
"Yes"
] | Please tell us when. | false | true | Answer all the questions that apply to you and your partner, if you have one. If you are filling this form in with a pen, write in black ink and use CAPITAL LETTERS. Please make sure that you complete the Consent in Part 2 and sign the Declaration in Part 12. If you do not fill this in, we will contact you and it may d... |
BI100A | form | Part 6: Details of the accident | Q51 | standard | What was the accident and how did it happen? What were you doing when the accident happened? | open_text | [] | Please give as much information as you can. | false | true | Answer all the questions that apply to you and your partner, if you have one. If you are filling this form in with a pen, write in black ink and use CAPITAL LETTERS. Please make sure that you complete the Consent in Part 2 and sign the Declaration in Part 12. If you do not fill this in, we will contact you and it may d... |
BI100A | form | Part 6: Details of the accident | Q52 | standard | Please describe the injuries caused by the accident | open_text | [] | Please give as much information as you can. For example, if you injured an arm, tell us if it was your left or your right arm. | false | true | Answer all the questions that apply to you and your partner, if you have one. If you are filling this form in with a pen, write in black ink and use CAPITAL LETTERS. Please make sure that you complete the Consent in Part 2 and sign the Declaration in Part 12. If you do not fill this in, we will contact you and it may d... |
Subsets and Splits
No community queries yet
The top public SQL queries from the community will appear here once available.