Welfare Support Questionnaire

First name

Last name

Birthday

Dia

Mês

Ano

Phone

Workplace name and address:

Payroll number

Job title:

Employer or contractor name:

How long have you been working there?

Do you have an employment contract?

Please explain briefly why you are requesting welfare support.

Are you currently unwell, injured, or experiencing any medical issues?

Do you have any disability or long-term condition that affects your work or daily life?

Have you provided medical evidence (e.g., doctor’s note, fit note)?

Are you currently receiving Statutory Sick Pay (SSP) or any other benefits?

Have you had any welfare meetings or reviews with your employer?

What outcome or support are you seeking from CAIWU?

Do you need assistance with workplace adjustments or other issues?

Is there anything else you would like to add or that we should know about your situation?