Self-Assessment
A self-assessment is a questionnaire that you fill out to explain the sort of work you think you can do now or in the future, and what support you might need to find and stay in work. We'll let you know if you need to complete one.
Who needs to complete a Self-Assessment
You may need to complete a Self-Assessment if you:
- have a health condition or disability that affects your ability to work
- need support or services to help you prepare for, find and stay in work.
You won't need to complete a Self-Assessment if you've got either:
- a job to return to within 13 weeks of when you applied for a benefit
- a medical certificate or other appropriate assessments which tells us that you:
- are more than 27 weeks pregnant
- are totally blind
- have a terminal illness
- have a severe intellectual or cognitive impairment
- have a condition which means you can no longer work and it's unlikely that this will change.
If you're unsure whether you need to complete one, contact us.
Completing a Self-Assessment
The Self-Assessment is available in different formats. Use the format that suits you best.
You can ask someone else to help you complete the Self-Assessment, or your case manager can help you.
When you meet with your case manager to discuss your Self-Assessment, you can use an interpreter. Contact us to arrange this.
Self-Assessment formats
Paper form
You can either:
- print the Self-Assessment below
- pick one up from one of our offices
- call us and we'll post one out to you.
You'll need to bring this completed form with you when you meet with us.
Self-Assessment questionnaire (PDF 204 KB)
Easy Read
You can read and answer the questions using the Easy Read version.
Easy Read uses pictures and short sentences to make it easier for people with learning disabilities or English as a second language. You can either:
- print the Easy Read form below
- pick one up from one of our offices
- call us and we'll post one out to you.
New Zealand Sign Language
You can watch a video of a person signing the Self-Assessment questions (Easy Read version). These videos aren't covered by Cheap as data.
You then need to either:
- answer the questions using one of the other formats,
- call us to arrange a sign language translator for when you meet with your case manager.
Large print
Please contact us to ask for this.
Braille
We can arrange for a copy of the Self-Assessment in braille to be sent to you.
Please contact us to ask for this.
Audio
Open transcript
00:00:00
Work and Income - Te Hiranga Tangata
00:00:04
Self-assessment questionnaire.
00:00:07
If you have a health condition, injury or disability, we need to understand how this impacts on your ability to work. We want you to tell us about your work background and your health. When you answer these questions, we'll be able to work out the best way to help you.
00:00:25
You can choose someone to help you answer the questions if you want.
00:00:30
How to fill in this questionnaire
00:00:33
To answer the questions you will need to tick the box next to the statement that you think best describes your situation or write in the space provided.
00:00:46
Please bring this questionnaire with you when you next meet with us.
00:00:51
If you have a Community Services Card or have received any financial help from us before, write your client number here. It can be found on your Community Services Card.
00:01:05
Client number.
00:01:07
Box, box, box, box, box, box, box, box, box.
00:01:16
Tell us your details.
00:01:19
One: what is your full name? 1st and middle names?
00:01:24
Surname or family name.
00:01:28
Two: what date were you born?
00:01:32
Day. Month. Year.
00:01:37
Three: Think about things like sport, hobbies, volunteering and work experience that you do or have done. What did you enjoy and what skills do you think you have gained?
00:01:51
Note tell us about your work, how to answer Question 3. This could include things like community work, organising church events, caring for children, using a computer, coaching sports teams. Describe the things you like to do, enjoy, and the skills you have gained.
00:02:13
End of note.
00:02:16
Four: what sort of work would you like to do in the future?
00:02:20
Five: what sort of work do you think you would be good at?
00:02:26
Six: What sort of jobs have you done in the past?
00:02:31
Tick the one that best describes the kind of work you have done.
00:02:36
Work I've done has mostly involved heavy physical work, Box
00:02:41
Work I've done did not involve much heavy physical work, Box
00:02:46
Work I've done has been a mix of jobs, some physical and some not, Box
00:02:52
I haven't had a job, Box.
00:02:57
Tell us what you expect
00:02:59
Seven: When do you expect to get a job? Or if you're working part time, when do you expect to increase your hours? Please tick one of the following.
00:03:09
Within the next three months, Box
00:03:12
Within the next six months, Box
00:03:15
Within the next 12 months, Box
00:03:18
In a couple of years, Box.
00:03:20
I don't think I will ever be able to work, Box.
00:03:25
I don't really know, Box.
00:03:30
Eight: when I get a job, I may need workplace support with.
00:03:36
Please tell us how much support you will need for each one.
00:03:41
Reading. Not at all, sometimes, most of the time.
00:03:47
Writing. Not at all, sometimes, most of the time.
00:03:52
Hearing and or talking with people. Not at all, sometimes, most of the time.
00:03:59
Physical access and or moving around at work. Not at all, sometimes, most of the time.
00:04:08
Lifting and carrying. Not at all, sometimes, most of the time.
00:04:14
Getting on with people at work. Not at all, sometimes, most of the time.
00:04:21
Learning new jobs, remembering things, or understanding what people want done. Not at all, sometimes, most of the time.
00:04:31
Managing tiredness or fatigue. Not at all, sometimes, most of the time.
00:04:38
Getting to and from the job. Not at all, sometimes, most of the time.
00:04:46
Managing medication. Not at all, sometimes, most of the time.
00:04:55
Nine: What do you think would help you get a job
00:04:59
Note how to answer question nine. This could include anything you think may help you get a job. End of note.
00:05:11
Ten: What do you think would stop you from getting a job?
00:05:15
Note how to answer question ten. This could include anything you think may get in the way of getting a job.
00:05:25
Eleven: is pain making it hard for you to do the sorts of things you want to do. Please tick one of the following.
00:05:33
No, not really, Box. Yes, a bit hard to do what I want, Box. Yes, quite hard to do what I want, Box.
00:05:44
Yes, the pain makes it extremely difficult to do what I want, Box.
00:05:51
Please bring this questionnaire with you when you next meet with us.
00:05:57
That concludes this recording of Work and Income, Te Hiranga Tangata, self-assessment Questionnaire. Read by Rosemary Ronald for the Royal New Zealand Foundation of the Blind.
Once you've listened to the audio, you need to either:
- answer the questions using one of the other formats above, or
- ask your case manager to help you answer it.