Expression of Interest
Please complete the Expression of Interest.
About Potential Participant
Title
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Mr
Mrs
Ms
Miss
Other
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First Name
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Middle Name(s)
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Last Name
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Date of Birth
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Minimum value is 01/01/1900. Maximum value is 31/12/2069.
Gender
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Female
Male
Other
Prefer not to say
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National Insurance Number (NINO)
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Contact Details
First line of Address
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Second line of Address
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Town or City
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Postcode
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Phone Number
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Email
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Preferred Contact Method
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Phone
Email
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Employment Status
What is the potential participant's current employment status?
Please Select
Not employed/self-employed
Employed
Self-employed
Both employed and self-employed
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Eligibility
Health and Disability Group - Eligibility Criteria (tick all that apply)
Disabled under the Equality Act 2010
Considers themselves disabled (Social Model of Disability)
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Health and Disability Group – Health Conditions (tick all that apply)
ADHD
Autism
Cancer
Chest or breathing problem, asthma or bronchitis
Chronic pain or fatigue condition, for example, fibromyalgia or ME
Dementia, for example, Alzheimer's disease
Depression, stress, anxiety or other mental health condition
Diabetes
Difficulty in hearing
Difficulty in seeing
Epilepsy
Heart, blood pressure or blood circulation condition
Joint, bone or muscle condition
Learning difficulty, for example, dyslexia or dyspraxia
Learning disability
Skin condition, severe disfigurement or allergy
Speech impediment
Stomach, liver, kidney or digestive problem
Other progressive condition
Other health condition or disability
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Specified Disadvantaged Group (tick all that apply)
An offender (someone who is serving a community service) or ex-offender (someone who has completed a custodial or community sentence)
A carer
An ex-carer
A homeless person
A former member of His Majesty’s (HM) Armed Forces (AF), a member of HM AF reserves, or a partner of current or former Armed Forces personnel
A person for whom a drug or alcohol dependency, including a history of dependency, presents barrier to employment
A care experienced young person or a care leaver
A refugee, a resettled Afghan
A person on the Ukrainian scheme
A victim/survivor of domestic abuse
A young person identified as being involved or at risk of being involved in serious violence
A victim of modern slavery
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Marketing
How did you find out about Connect to Work?
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Primary Care (Health Providers)
Community Care (Inc Third Party Organisations)
Employer
Jobcentre Plus
Self-Referral
Other
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If 'Other' please specify
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Submitting will create/update the participant MI record.
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