Employment Support Allowance Questionnaire

An employment support allowance questionnaire is the type of a questionnaire which is issued by a company to know whether or not an applicant satisfies the necessary criteria to be eligible for the employment support allowance. Employment support allowance is given to those who are in anyway incapable of performing a set of duties.

The questionnaire is used to gather information about the applicant and helps the authorities to come to a conclusion about the eligibility of the applicant for ESA or employment support allowance. Given below is a well detailed sample of an employment support allowance questionnaire that can be used by anyone for the purpose of reference.

Sample Employment Support Allowance Questionnaire

Name of the applicant:

Age of the applicant:

Date of birth of the applicant:

Gender of the applicant:

Full residential address with pin code:


Contact number:

Email ID of applicant:

Kindly provide your answers to all the following given questions in the spaces given:

Q1. Are you medically ill or disabled in any way?

a)      Yes

b)      No

c)      partially

Q2. Does this medical condition restrict you in any way to perform certain tasks?

a)      Yes

b)      No

c)      Sometimes or in certain cases

Q3. If yes, then please explain in detail the kind of restrictions you face.


Q4. Why do you think that you should be given employment support allowance?


Q5. Do you require financial support of personalized help?

a)      Employment support

b)      Personalized help

Q6. Is there any other working or earning member in your family?

a)      Yes

b)      No

Q7. If yes, then what is the total monthly income of your family?


Q8. Have you attached the proof documents in order to support your answers with this questionnaire?

a)      Yes

b)      No

c)      I don’t know which documents to attach

Category: Employment Questionnaire

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