Work Capability self-assessment

1a. Cannot either (i) mobilise more than 50 meters on level ground without stopping in order to avoid significant discomfort or exhaustion or (ii) repeatedly mobilise 50 meters within a reasonable timescale because of significant discomfort or exhaustion. (15 points)

1b. Cannot mount or descend two steps unaided by another person even with the support of a handrail. (9 points)

1c. Cannot either (i) mobilise more than 100 meters on level ground without stopping in order to avoid significant discomfort or exhaustion or (ii) repeatedly mobilise 100 meters within a reasonable timescale because of significant discomfort or exhaustion. (9 points)

1d. Cannot either (i) mobilise more than 200 metres on level ground without stopping in order to avoid significant discomfort or exhaustion or (ii) repeatedly mobilise 200 meters within a reasonable timescale because of significant discomfort or exhaustion. (6 points)

1e. None of the above apply. (0 points)

2a. Cannot move between one seated position and another seated position located next to one another without receiving physical assistance from another person. (15 points)

2b. Cannot, for the majority of the time, remain at a work station, either: (i) standing unassisted by another person (even if free to move around) or; (ii) sitting (even in an adjustable chair); or (iii) a combination of (i) and (ii), for more than 30 minutes, before needing to move away in order to avoid significant discomfort or exhaustion. (9 points)

2c. Cannot, for the majority of the time, remain at a work station, either: (i) standing unassisted by another person (even if free to move around) or; (ii) sitting (even in an adjustable chair); or (iii) a combination of (i) and (ii), for more than an hour, before needing to move away in order to avoid significant discomfort or exhaustion. (6 points)

2d. None of the above apply. (0 points)

3a. Cannot raise either arm as if to put something in the top pocket of a coat or jacket. (15 points)

3b. Cannot raise either arm to top of head as if to put on a hat. (9 points)

3c. Cannot raise either arm above head height as if to reach for something. (6 points)

3d. None of the above apply. (0 points)

4a. Cannot pick up and move a 0.5 litre carton full of liquid. (15 points)

4b. Cannot pick up and move a one litre carton full of liquid. (9 points)

4c. Cannot transfer a light but bulky object such as an empty cardboard box. (6 points)

4d. None of the above apply. (0 points)

5a. Cannot either: (i) press a button, such as a telephone keypad or; (ii) turn the pages of a book with either hand. (15 points)

5b. Cannot pick up a 1 pound coin or equivalent with either hand. (15 points)

5c. Cannot use a pen or pencil to make a meaningful mark. (9 points)

5d. Cannot single-handedly use a suitable keyboard or mouse. (9 points)

5e. None of the above apply. (0 points)

6a. Cannot convey a simple message, such as the presence of a hazard. (15 points)

6b. Has significant difficulty conveying a simple message to strangers. (15 points)

6c. Has some difficulty conveying a simple message to strangers. (6 points)

6d. None of the above apply. (0 points)

7a. Cannot understand a simple message due to sensory impairment, such as the location of a fire escape. (15 points)

7b. Has significant difficulty understanding a simple message from a stranger due to sensory impairment. (15 points)

7c. Has some difficulty understanding a simple message from a stranger due to sensory impairment. (6 points)

7d. None of the above apply. (0 points)

8a. Unable to navigate around familiar surroundings, without being accompanied by another person, due to sensory impairment. (15 points)

8b. Cannot safely complete a potentially hazardous task such as crossing the road, without being accompanied by another person, due to sensory impairment. (15 points)

8c. Unable to navigate around unfamiliar surroundings, without being accompanied by another person, due to sensory impairment. (9 points)

8d. None of the above apply. (0 points)

9a. At least once a month experiences (i) loss of control leading to extensive evacuation of the bowel and/or voiding of the bladder; or (ii) substantial leakage of the contents of a collecting device; sufficient to require cleaning and a change in clothing. (15 points)

9b. The majority of the time is at risk of loss of control leading to extensive evacuation of the bowel and/or voiding of the bladder, sufficient to require cleaning and a change in clothing, if not able to reach a toilet quickly. (6 points)

9c. None of the above apply. (0 points)

10a. At least once a week, has an involuntary episode of lost or altered consciousness resulting in significantly disrupted awareness or concentration. (15 points)

10b. At least once a month, has an involuntary episode of lost or altered consciousness resulting in significantly disrupted awareness or concentration. (6 points)

10c. None of the above apply. (0 points)

11a. Cannot learn how to complete a simple task, such as setting an alarm clock. (15 points)

11b. Cannot learn anything beyond a simple task, such as setting an alarm clock. (9 points)

11c. Cannot learn anything beyond a moderately complex task, such as the steps involved in operating a washing machine to clean clothes. (6 points)

11d. None of the above apply. (0 points)

12a. Reduced awareness of everyday hazards leads to a significant risk of: (i) injury to self or others; or (ii) damage to property or possessions, such that they require supervision for the majority of the time to maintain safety. (15 points)

12b. Reduced awareness of everyday hazards leads to a significant risk of (i) injury to self or others; or (ii) damage to property or possessions, such that they frequently require supervision to maintain safety. (9 points)

12c. Reduced awareness of everyday hazards leads to a significant risk of: (i) injury to self or others; or (ii) damage to property or possessions, such that they occasionally require supervision to maintain safety. (6 points)

12d. None of the above apply. (0 points)

13a. Cannot, due to impaired mental function, reliably initiate or complete at least 2 sequential personal actions. (15 points)

13b. Cannot, due to impaired mental function, reliably initiate or complete at least 2 personal actions for the majority of the time. (9 points)

13c. Frequently cannot, due to impaired mental function, reliably initiate or complete at least 2 personal actions. (6 points)

13d. None of the above apply. (0 points)

14a. Cannot cope with any change to the extent that day to day life cannot be managed. (15 points)

14b. Cannot cope with minor planned change (such as a pre-arranged change to the routine time scheduled for a lunch break), to the extent that overall day to day life is made significantly more difficult. (9 points)

14c. Cannot cope with minor unplanned change (such as the timing of an appointment on the day it is due to occur), to the extent that overall, day to day life is made significantly more difficult. (6 points)

14d. None of the above apply. (0 points)

15a. Cannot get to any place outside the claimant's home with which the claimant is familiar. (15 points)

15b. Is unable to get to a specified place with which the claimant is familiar, without being accompanied by another person. (9 points)

15c. Is unable to get to a specified place with which the claimant is unfamiliar without being accompanied by another person. (6 points)

15d. None of the above apply. (0 points)

16a. Engagement in social contact is always precluded due to difficulty relating to others or significant distress experienced by the individual. (15 points)

16b. Engagement in social contact with someone unfamiliar to the claimant is always precluded due to difficulty relating to others or significant distress experienced by the individual. (9 points)

16c. Engagement in social contact with someone unfamiliar to the claimant is not possible for the majority of the time due to difficulty relating to others or significant distress experienced by the individual. (6 points)

16d. None of the above apply. (0 points)

17a. Has, on a daily basis, uncontrollable episodes of aggressive or disinhibited behaviour that would be unreasonable in any workplace. (15 points)

17b. Frequently has uncontrollable episodes of aggressive or disinhibited behaviour that would be unreasonable in any workplace. (15 points)

17c. Occasionally has uncontrollable episodes of aggressive or disinhibited behaviour that would be unreasonable in any workplace. (9 points)

17d. None of the above apply. (0 points)

18a. At least once a week experiences (i) loss of control leading to extensive evacuation of the bowel and/or voiding of the bladder; or (ii) substantial leakage of the contents of a collecting device; sufficient to require the individual to clean themselves and change clothing.

18b. This does not apply to me.

19a. Cannot convey food or drink to the claimant's own mouth without receiving physical assistance from someone else;

19b. Cannot convey food or drink to the claimant's own mouth without repeatedly stopping, experiencing breathlessness or severe discomfort;

19c. Cannot convey food or drink to the claimant's own mouth without receiving regular prompting given by someone else in the claimant's physical presence; or

19d. Owing to a severe disorder of mood or behaviour, fails to convey food or drink to the claimant's own mouth without receiving - (i) physical assistance from someone else; or (ii) regular prompting given by someone else in the claimant's presence.

19e. This does not apply to me.

20a. Cannot chew or swallow food or drink;

20b. Cannot chew or swallow food or drink without repeatedly stopping, experiencing breathlessness or severe discomfort;

20c. Cannot chew or swallow food or drink without repeatedly receiving regular prompting given by someone else in the claimant's presence; or

20d. Owing to a severe disorder of mood or behaviour, fails to- (i) chew or swallow food or drink; or (ii) chew or swallow food or drink without regular prompting given by another person in the physical presence of the claimant.

20e. This does not apply to me.

21a. Yes

21b. No

22a. Yes

22b. No

23a. Yes

23b. No

24a. Yes

24b. No

25a. Yes

25b. No

26a. Yes

26b. No

27a. Yes

27b. No

28a. Yes

28b. No

29a. Yes

29b. No

30a. Yes

30b. No

31a. Yes

31b. No