Self-Assessment

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Work and Income - Te Hiranga Tangata

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Self-assessment questionnaire.

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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.

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You can choose someone to help you answer the questions if you want.

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How to fill in this questionnaire

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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.

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Please bring this questionnaire with you when you next meet with us.

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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.

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Client number.

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Box, box, box, box, box, box, box, box, box.

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Tell us your details.

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One: what is your full name? 1st and middle names?

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Surname or family name.

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Two: what date were you born?

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Day. Month. Year.

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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?

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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.

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End of note.

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Four: what sort of work would you like to do in the future?

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Five: what sort of work do you think you would be good at?

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Six: What sort of jobs have you done in the past?

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Tick the one that best describes the kind of work you have done.

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Work I've done has mostly involved heavy physical work, Box

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Work I've done did not involve much heavy physical work, Box

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Work I've done has been a mix of jobs, some physical and some not, Box

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I haven't had a job, Box.

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Tell us what you expect

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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.

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Within the next three months, Box

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Within the next six months, Box

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Within the next 12 months, Box

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In a couple of years, Box.

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I don't think I will ever be able to work, Box.

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I don't really know, Box.

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Eight: when I get a job, I may need workplace support with.

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Please tell us how much support you will need for each one.

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Reading. Not at all, sometimes, most of the time.

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Writing. Not at all, sometimes, most of the time.

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Hearing and or talking with people. Not at all, sometimes, most of the time.

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Physical access and or moving around at work. Not at all, sometimes, most of the time.

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Lifting and carrying. Not at all, sometimes, most of the time.

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Getting on with people at work. Not at all, sometimes, most of the time.

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Learning new jobs, remembering things, or understanding what people want done. Not at all, sometimes, most of the time.

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Managing tiredness or fatigue. Not at all, sometimes, most of the time.

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Getting to and from the job. Not at all, sometimes, most of the time.

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Managing medication. Not at all, sometimes, most of the time.

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Nine: What do you think would help you get a job

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Note how to answer question nine. This could include anything you think may help you get a job. End of note.

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Ten: What do you think would stop you from getting a job?

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Note how to answer question ten. This could include anything you think may get in the way of getting a job.

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Eleven: is pain making it hard for you to do the sorts of things you want to do. Please tick one of the following.

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No, not really, Box. Yes, a bit hard to do what I want, Box. Yes, quite hard to do what I want, Box.

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Yes, the pain makes it extremely difficult to do what I want, Box.

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Please bring this questionnaire with you when you next meet with us.

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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.