Pip Application Form Online Details

Most people use pip to install Python packages. It is one of the most popular programming languages in the world, and it's free! Pip does not fulfill all installation needs though. This blog post introduces you to Blank Pip Form, a tool that helps you create your own custom python distribution. You can then upload this distribution anywhere on the internet for other people to download and execute code with your custom package management system without needing any other tools or setup! The article also goes into detail about how you might want to use this tool in various situations like education, research labs, startups etc.

You will see info about the type of form you wish to fill out in the table. It can tell you how long it will take to fill out blank pip form, exactly what parts you will need to fill in, and so forth.

QuestionAnswer
Form NameBlank Pip Form
Form Length37 pages
Fillable?No
Fillable fields0
Avg. time to fill out9 min 15 sec
Other namespip form, dwp pip application form download, pip application form pdf, pip application form download pdf 2020

Form Preview Example

Personal Independence Payment

How your disability affects you

Full name

National Insurance (NI) number

only

Please fill in this form and return it to us straightaway.

We’ve sent you an Information Booklet to help you complete the

form. In the Information Booklet we:

If you need to ask for more time to compl te this form please call suse on 0800 121 4433 (0800 121 4493 if using a t xtphon ).

• give advice on where you can get help to complete the f rm

• explain the questions we ask

• tell you how to answer the questions, and

• give you examples of other things you can tell us

If you don't return this form to us and we don't hear from you to ask for more time to complete t, we ay end your claim to PIP.

If you don't want to ont nue w th your claim and w n’t be etu ning this form, please call us on 0800 121 4433 (0800 121 4493 if using a textphone).

What you n d to do

Step 1

– Read through this form and the Inf

rma ion Booklet.

Step 2

– Fill in this form (in pen) to tell us h

for

w y ur health condition

 

or disability affects you.

 

tep 3

– Read and sign the declarati n n page 32.

tep 4

– Return the form to us with photocopies of any additional

Specimeninformation. Not

PIP2 June 2018

1 of 33

Additional information to support your claim

As well as completing this form it is important that you help us to understand your needs by providing additional information. This should explain how your health condition or disability affects your daily life.

Do send information that shows how your health condition or disability affects you carrying out day-to-day activities.

Don’t send general information about your condition like fact sheets or information from the internet.

Only send us photocopies of information you already have available to you. We can’t return any documents to you.

There is more information, including examples of what to send us in the Information Booklet we sent you with this form.

only

Please put your name and National Insurance number

n the t p f

use

each document.

 

 

 

 

 

Specimen

 

Section 1 – About your health prof ssio

als

 

If we need additional information we may contact the h

alth professionals that upport you.

Q1 Tell us about the professional(s) best placed to advise s on how your health condition or d sab l ty affects you

For example, a GP, hospital doctor, spec alist nurse, community psychiatric nurse, occupational

therapist, physiotherapist, so

al worker, counsell

r, r supp t w

ker.

Name

 

 

 

 

 

 

 

 

 

 

 

 

Address

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

for

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Postcode

Profession

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Phone number including the

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

dialling code

 

 

 

 

 

 

When did you last see them?

 

 

 

 

 

 

/

/

 

 

(approximate date)

Not

 

 

 

 

 

 

 

 

PIP2 June 2018

2 of 33

Section 1 – About your health professionals continued

Name

 

 

 

 

 

 

 

Address

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Postcode

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Profession

 

 

 

 

only

 

 

 

 

 

 

 

Phone number including the

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

dialling code

 

 

 

 

 

 

 

When did you last see them?

 

 

 

 

 

 

 

/

/

 

 

 

(approximate date)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Specimen

 

 

 

Name

 

 

 

 

 

 

 

Address

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Po tcode

Profession

 

 

 

 

 

 

 

Phone number including the

 

 

for

use

dialling code

 

 

 

 

 

 

 

When did you last s th m?

 

/

/

 

 

 

(approximate dat )

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Not

 

 

 

 

If you need to add more please c

ntinue at Q15 Additional information.

PIP2 June 2018

3 of 33

Section 2 - About your health condition or disability

iUse page 7 of the Information Booklet to help you answer these questions.

Q2a - Tell us in the space below:

what your health conditions or disabilities are, and

approximately when each of these started

 

 

 

 

Health condition or disability

 

only

 

 

Approximate start date

 

Example: Diabetes

 

May 2010

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Specimen

 

 

 

for

 

We will ask you how your health ond t ons or disabilities affect h w useyou

carry out day-to-day a tivities in the rest of the

rm.

If you need to add more pl ase ontinue at Q15 Additional inf rmation.

Not

 

 

 

PIP2 June 2018

4 of 33

Section 2 - About your health condition or disability continued

Q2b - Tell us about:

tablets or other medication you’re taking or will be taking and the dosage

any treatments you’re having or will be having, such as chemotherapy, physiotherapy or dialysis

any side effects these have on you

 

only

Specimen

use

Not

for

 

If you need to add more please continue at Q15 Additional information.

PIP2 June 2018

5 of 33

Section 3 - How your health condition or disability affects your day-to-day life

Tell us in the rest of this form how your health conditions or disabilities affect your day-to-day activities.

Q3 - Preparing Food

i Use page 7 of the Information Booklet to help answer these questions.

Tell us about whether you can prepare a simple one course meal for one from fresh ingredients.

This includes things like:

 

 

 

 

 

 

food preparation such as peeling, chopping or opening packagi g, a d

safely cooking or heating food on a cooker hob or in a microwave oven

Tick the boxes that apply to you, then provide more informati

in the

Extra information box.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

use

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Specimen

 

Q3a - Do you need to use an aid

 

Yes

 

only

 

or appliance to prepare or

 

No

 

 

cook a simple meal?

 

 

 

 

Aids and appliances

 

 

Som tim s

 

 

 

include things like:

 

 

 

 

 

 

 

• perching stools,

 

 

 

 

 

 

 

lightweight pots and

 

 

 

 

 

 

pans, easy grip handles

 

 

for

 

 

• do they remind or

 

 

 

 

 

on utensils, single lever

 

 

 

 

 

 

arm taps and liqu d level

 

 

 

 

 

 

indicators

 

 

 

 

 

 

 

Q3b – Do you n

d h lp from

 

Yes

 

 

 

 

anoth r

rson to pr pare

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Not

 

 

 

 

or cook a sim le m al?

 

No

 

 

 

 

By this we m an:

 

 

S me imes

 

 

 

motivate you to cook?

 

 

 

 

 

 

• do they plan the task f r

 

 

 

 

 

 

you?

 

 

 

 

 

 

 

 

• do they supervise you?

 

 

 

 

 

 

• do they physically help

 

 

 

 

 

 

you?

 

 

 

 

 

 

 

 

• do they prepare all your

 

 

 

 

 

 

food for you?

 

 

 

 

 

 

 

This includes help you

 

 

 

 

 

 

have, and help you need

 

 

 

 

 

 

but don’t get.

 

 

 

 

 

 

PIP2 June 2018

6 of 33

Q3c - Extra information - Preparing Food

Tell us more about any difficulties you have when preparing and cooking food:

• tell us how your condition affects you doing this activity

 

 

 

tell us how you manage at the moment and the problems you have when you can't

 

do this activity

 

 

 

 

tell us how long it takes to prepare and cook food

 

 

 

does whether you can do this vary throughout the day? Tell us about good and bad

 

days

 

only

can you cook using an oven safely? If not, tell us why not

tell us about the aids or appliances you need to use to help you prepare and cook

 

food

 

 

 

 

do you experience any other difficulties, either during or after the activity, ike pain,

 

breathlessness or tiredness?

 

 

 

 

tell us about the help you need from another person when prepari g f od. This

 

includes help you have and help you need but don't get

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

use

 

 

 

 

 

 

 

 

Specimen

 

 

 

 

 

for

 

 

 

 

 

 

 

 

Not

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

If you need to add more please continue at Q15 Additional information.

PIP2 June 2018

7 of 33

Q4 - Eating and drinking

iUse page 7 of the Information Booklet to help answer these questions.

Tell us about whether you can eat and drink.

This means:

remembering when to eat

cutting food into pieces

putting food and drink in your mouth, and

chewing and swallowing food and drink

 

 

 

 

 

 

only

Tick the boxes that apply to you, then provide more information in the

Extra information box.

 

 

 

 

 

 

Q4a – Do you need to use an aid

 

Yes

 

 

 

or appliance to eat and

 

No

 

 

 

drink?

 

 

 

 

 

 

Aids and appliances

 

 

Sometimes

 

 

 

 

 

 

include things like:

 

 

 

use

 

 

 

 

 

Specimen

 

 

• weighted cups, adapted

 

 

 

 

 

cutlery

 

 

 

 

 

 

 

Q4b – Do you use a feeding tube

 

Y s

 

 

 

or similar device to eat

 

No

 

 

 

or drink?

 

 

 

 

 

 

This means things l ke a

 

So eti es

 

 

feeding tube with a rate

 

 

for

 

limiting devi e as a

 

 

 

 

 

 

delivery system or feed

 

 

 

 

 

pump.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Q4c – Do you n

 

Not

 

 

 

d h lp from

 

Yes

 

 

 

anoth r

rson to at and

 

No

 

 

 

drink?

 

 

 

 

 

 

By this we mean:

 

 

S metimes

 

 

• do they remind you to eat

 

 

 

 

 

and drink?

 

 

 

 

 

 

• do they supervise you?

 

 

 

 

 

• do they physically help

 

 

 

 

 

you to eat and drink?

 

 

 

 

 

• do they help you manage

 

 

 

 

 

a feeding tube?

 

 

 

 

 

 

This includes help you have and help you need but don't get.

PIP2 June 2018

8 of 33

Q4d - Extra information - Eating and drinking

Tell us more about any difficulties you have when eating and drinking:

• tell us how your condition affects you doing this activity

 

 

 

tell us how you manage at the moment and the problems you have when you can't

 

do this activity

 

 

 

 

tell us how long it takes you to complete this activity

 

 

 

does whether you can do this vary throughout the day? Tell us about good and bad

 

days

 

only

 

 

 

 

 

do you experience any other difficulties, either during or after the activity, ike pain,

 

breathlessness or tiredness?

 

 

 

 

tell us about the aids and appliances you need to use to help you eat and drink

tell us about the help you need from another person when eati g a d dri ki g. This

 

includes help you have and help you need but don't get

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

use

 

 

 

 

 

 

 

 

Specimen

 

 

 

 

for

 

 

 

 

 

 

 

 

Not

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

If you need to add more please continue at Q15 Additional information.

PIP2 June 2018

9 of 33

Q5 – Managing treatments

iUse page 8 of the Information Booklet to help answer these questions

Tell us about whether you can monitor changes in your health condition, take medication or manage any treatments carried out at home. Monitoring changes include things like:

• monitoring blood sugar level, changes in mental state and pain levels

A home treatment includes things like:

 

 

only

 

 

 

 

• physiotherapy and home dialysis

 

 

 

 

Tick the boxes that apply to you then provide more information in the Extra

information box.

 

 

 

 

 

 

 

Q5a – Do you need to use an aid

 

 

Yes

 

 

 

 

 

 

 

 

or appliance to monitor

 

 

No

 

 

 

 

 

 

 

 

your health conditions,

 

 

 

 

 

take medication or

 

 

 

Sometimes

 

use

 

 

 

 

 

 

 

 

 

Specimen

 

 

manage home

 

 

 

 

 

 

 

treatments?

 

 

 

 

 

 

 

For example, using a

 

 

 

 

 

 

 

Dosette Box for tablets.

 

 

 

 

Q5b – Do you need help from

 

Y s

 

 

 

another person to

 

 

 

No

for

 

monitor your health

 

 

 

 

 

 

conditions, take

 

 

 

So eti es

 

 

medication or manage

 

 

 

 

 

home treatments?

 

 

 

 

 

 

 

By this we m an:

 

 

 

 

 

 

 

• do th y r mind you to

 

 

 

 

take m dications and

 

 

 

 

treatm nt?

Not

 

 

 

 

 

 

 

 

 

 

• do th y su rvise you while you take your medication?

• do they physically help you take medication or manage treatments?

This includes help you have and help you need but don't get.

PIP2 June 2018

10 of 33

Q5c – Extra information - Managing treatments

Tell us more about any difficulties you have with managing your treatments:

• tell us how your condition affects you doing this activity

 

 

 

tell us how you manage at the moment and the problems you have when you can't

 

do this activity

 

 

 

 

tell us how long it takes you to manage your treatments

 

 

 

does whether you can do this vary throughout the day? Tell us about good and bad

 

days

 

only

 

 

 

 

 

do you experience any other difficulties, either during or after the activity, ike pain,

 

breathlessness or tiredness?

 

 

 

 

tell us about the aids or appliances you need to use to help you monitor our

 

treatment

 

 

 

 

tell us about the help you need from another person when ma

agi g your

 

treatments. This includes help you have and help you need but d

't get

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

use

 

 

 

 

 

 

 

 

Specimen

 

 

 

 

 

for

 

 

 

Not

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

If you need to add more please continue at Q15 Additional information.

PIP2 June 2018

11 of 33

Q6 – Washing and bathing

iUse page 8 of the Information Booklet to help answer these questions.

Tell us about whether you can wash and bathe.

This means things like:

washing your body, limbs, face, underarms and hair, and

using a standard bath or shower

 

 

 

 

 

only

This doesn't include any difficulties you have getting to the bathroom.

Tick the boxes that apply to you then provide more information in the Extra

information box.

 

 

 

 

 

 

Q6a – Do you need to use an aid

 

Yes

 

 

 

or appliance to wash and

 

No

 

 

 

bathe yourself, including

 

 

 

 

using a bath or shower?

 

Sometimes

 

 

 

 

 

Aids and appliances

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Specimen

 

 

include things like:

 

 

 

 

 

 

• bath / shower seat,

 

 

 

 

 

 

grab rails

 

 

 

 

 

 

Q6b – Do you need help from

 

Y s

 

 

use

another person to wash

 

No

 

 

and bathe?

 

 

 

 

By this we mean:

 

 

So eti es

 

• do they physically help

 

 

for

you?

 

 

 

• do they tell you when to

 

 

wash and bath ?

 

 

 

 

• do th y wat h ov r you to

 

 

 

make sure you are saf ?

 

 

 

 

Not

 

This includ s help you have

 

 

 

and help you n d but

 

 

 

don't get.

 

 

 

 

PIP2 June 2018

12 of 33

Q6c – Extra information - Washing and bathing

Tell us more about any difficulties you have when washing and bathing:

• tell us how your condition affects you doing this activity

 

 

tell us how you manage at the moment and the problems you have when you can't

 

do this activity

 

 

 

tell us how long it takes you to wash and bathe

 

 

 

does whether you can do this vary throughout the day? Tell us about good and bad

days

only

 

do you have difficulty washing particular parts of your body? Which parts?

does it take you a long time to wash and bathe?

 

 

 

do you experience any other difficulties, either during or after the activity, ike pain,

 

breathlessness or tiredness?

 

 

 

tell us about the aids or appliances you need to help you wash a d bathe

tell us about the help you need from another person when washi g a d bathing.

 

This includes help you have and help you need but don't get

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

use

 

 

 

 

 

 

 

 

 

 

 

 

Specimen

 

 

 

 

for

 

 

 

 

 

 

 

 

Not

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

If you need to add more please continue at Q15 Additional information.

PIP2 June 2018

13 of 33

Q7 – Managing toilet needs

iUse page 8 of the Information Booklet to help answer these questions.

Tell us about whether you can use the toilet and manage incontinence.

Using the toilet means:

being able to get on or off a standard toilet, and

cleaning yourself after using the toilet

toilet or manage

 

 

No

 

only

Managing incontinence means:

 

 

 

 

 

• emptying your bowel and bladder, including if you need a collecting

device such as a bottle, bucket or catheter, and

 

 

 

• cleaning yourself after doing so

 

 

 

 

 

This doesn't include difficulties you have getting to the bathroom.

 

Tick the boxes that apply to you then provide more informati

in the Extra

information box.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

use

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SpecimenThis includes help you have

 

Q7a – Do you need to use an aid

 

Yes

 

 

 

or appliance to use the

 

 

 

 

 

incontinence?

 

 

Som tim s

 

 

Aids and appliances

 

 

 

 

 

 

include things like:

 

 

 

 

 

 

• commodes, raised toilet

 

 

 

 

 

seats, bottom wipers,

 

 

for

 

bidets, incontinence pads

 

 

 

 

 

 

 

 

or a stoma bag

 

 

 

 

 

 

Q7b – Do you n

d h lp from

 

 

 

 

 

 

Yes

 

 

 

 

 

 

 

anoth r p rson to use the

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

toilet or manage

Not

 

 

 

 

 

No

 

 

 

incontinenc ?

 

 

S me imes

 

 

By this we mean:

 

 

 

 

 

 

• do they

hysically help

 

 

 

 

 

you?

 

 

 

 

 

 

 

• do they tell you when to use the toilet?

• do they watch over you to make sure you are safe?

and help you need but don't get.

PIP2 June 2018

14 of 33

Q7c – Extra information - Managing toilet needs

Tell us more about any difficulties you have with your toilet needs or incontinence:

• tell us how your condition affects you doing this activity

 

 

 

 

tell us how your manage at the moment and the problems you have when you can't

 

do this activity

 

 

 

 

 

tell us how long it takes you to complete this activity

 

 

 

 

does whether you can do this vary throughout the day? Tell us about good and bad

 

days

 

only

 

 

 

 

 

 

are you incontinent? Tell us in what way and how you manage it

 

 

 

do you experience any other difficulties, either during or after the activity, ike pain,

 

breathlessness or tiredness?

 

 

 

 

 

tell us about the aids or appliances you need to use to help you ma

age our toi et

 

needs

 

 

 

 

 

tell us about the help you need from another person when ma agi

g your toilet

 

needs. This includes help you have and help you need but d 't get

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

use

 

 

 

 

 

 

 

 

Specimen

 

 

 

 

 

for

 

 

 

 

 

 

 

 

 

 

Not

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

If you need to add more please continue at Q15 Additional information.

PIP2 June 2018

15 of 33

Q8 – Dressing and undressing

iUse page 9 of the Information Booklet to help answer these questions.

Tell us about whether you can dress or undress yourself

 

 

This means:

 

 

 

 

 

 

putting on and taking off clothes, including shoes and socks

 

knowing when to put on or take off clothes, and

 

 

 

being able to select clothes that are appropriate

 

only

 

 

 

 

 

 

Tick the boxes that apply to you then provide more information in the Extra

information box.

 

 

 

 

 

 

Q8a – Do you need to use an aid

 

Yes

 

 

 

 

 

 

 

 

or appliance to dress or

 

No

 

 

 

 

 

 

 

 

 

undress?

 

 

 

 

 

 

Aids and appliances

 

 

Sometimes

 

 

 

 

 

 

 

 

include things like:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

• modified buttons, front

 

 

 

 

use

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Specimen

 

 

 

fastening bras, velcro

 

 

 

 

 

 

fastening, shoe aids or an

 

 

 

 

 

 

audio colour detector

 

 

 

 

 

Q8b – Do you need help from

 

Y s

 

 

 

 

another person to dress

 

No

 

 

 

 

or undress?

 

 

for

 

 

By this we mean:

 

 

So eti es

 

 

 

• do they physi ally help

 

 

 

 

 

 

you?

 

 

 

 

 

 

 

• do they sele t your

 

 

 

 

 

 

 

cloth s?

 

 

 

 

 

 

 

• do th y tell you wh

n to

 

 

 

 

 

 

dress and undr ss?

Not

 

 

 

 

• do th y tell you wh

 

 

 

 

n to

 

 

 

 

 

change your cloth s?

This includes help you have and help you need but don't get.

PIP2 June 2018

16 of 33

Q8c – Extra Information - Dressing and undressing

Tell us more about any difficulties you have when dressing and undressing:

• tell us how your condition affects you doing this activity

 

 

 

tell us how you manage at the moment and the problems you have when you can't

 

do this activity

 

 

 

 

tell us how long it takes you to dress and undress

 

 

 

does whether you can dress or undress yourself vary throughout the day? Tell us

 

about good and bad

 

only

 

 

 

 

 

do you only have difficulty dressing certain parts of your body? Which parts?

do you experience any other difficulties, either during or after the activity, ike pain,

 

breathlessness or tiredness?

 

 

 

 

tell us about the aids or appliances you need to help with dressi g a d u dressing

tell us about the help you need from another person when dressi

g a d

 

undressing. This includes help you have and help you need but d

't get

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

use

 

 

 

 

 

 

 

 

Specimen

 

 

 

 

for

 

 

 

Not

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

If you need to add more please continue at Q15 Additional information.

PIP2 June 2018

17 of 33

Q9 – Communicating

iUse page 9 of the Information Booklet to help answer these questions.

Tell us about whether you have difficulties with your speech, your hearing or your understanding of what is being said to you.

This means in your native spoken language

Tick the boxes that apply to you then provide more information in the Extra

information box.

 

 

 

 

only

 

 

 

 

 

 

Q9a – Do you need to use an

 

Yes

 

 

 

 

 

 

 

aid or appliance to

 

 

No

 

 

 

 

 

 

 

 

communicate with

 

 

 

 

 

others?

 

 

Sometimes

 

 

 

 

 

 

Aids and appliances

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

include things like:

 

 

 

 

 

 

• hearing and voice aids

 

 

 

 

use

• picture symbols, and

 

 

 

 

Specimen

 

 

• assistive computer

 

 

 

 

 

 

technology

 

 

 

 

 

 

Q9b – Do you need help from

 

Y s

 

 

 

another person to

 

 

No

 

 

 

communicate with

 

 

 

 

 

others?

 

 

So eti es

 

 

By this we mean:

 

 

 

for

 

• do they help you

 

 

 

 

understand what people

 

 

 

are saying?

 

 

 

 

• do you have som one

 

 

 

who helps you by

 

 

 

 

interpr ting sp ch into

 

 

 

sign languag ?

Not

 

 

 

 

 

• do th y help you by

 

 

 

 

s eaking on your behalf?

 

 

 

This includes help you have and help you need but don't get.

PIP2 June 2018

18 of 33

Q9c – Extra information - Communicating

Tell us more about any difficulties you have with your speech, your hearing and your

understanding of what is said to you:

 

 

 

 

 

• tell us how your condition affects you doing this activity

 

 

 

 

tell us how you manage at the moment and the problems you have when you can't do

 

this activity

 

 

 

 

 

tell us how long it takes you to complete this activity

only

 

 

does whether you can do this vary throughout the day? Tell us about good and bad

 

days

 

 

 

 

 

do you experience any other difficulties either during or after the activity, ike anxiety

 

and distress?

 

 

 

 

 

tell us about the aids or appliances you need to help you to commu

icate

tell us about the help you need from another person when commu

icati g. This

 

includes help you have and help you need but don't get

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

use

 

 

 

 

 

 

 

 

Specimen

 

 

 

 

 

for

 

 

 

 

 

 

 

 

 

 

Not

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

If you need to add more please continue at Q15 Additional information.

PIP2 June 2018

19 of 33

Q10 – Reading

iUse page 9 of the Information Booklet to help you answer these questions.

Tell us about whether you can read and understand signs, symbols and words in your native language. Also tell us about difficulties you have concentrating when doing so.

This means:

 

 

 

 

 

only

 

 

 

 

 

 

signs, symbols and words written or printed in your native language, not braille

understanding numbers, including dates

 

 

 

• other instructions, such as timetables

 

 

 

 

Tick the boxes that apply to you then provide more information in the Extra

information box.

 

 

 

 

 

 

 

Q10a – Do you need to use an

 

 

Yes

 

 

 

 

 

 

 

 

aid or appliance other

 

 

No

 

 

 

 

 

 

 

 

 

 

than spectacles or

 

 

 

 

 

 

 

contact lenses to read

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Specimen

 

 

 

signs, symbols and

 

 

 

Sometimes

 

 

 

words?

 

 

 

 

 

 

 

 

Aids and appliances

 

 

 

 

 

 

 

 

include things like

 

 

 

 

 

 

 

 

magnifiers.

 

 

 

 

 

 

 

Q10b – Do you need help from

 

 

Yes

 

 

use

 

another person to read

 

 

No

 

 

 

or understand signs,

 

 

 

 

 

symbols and words?

 

 

Sometimes

 

 

By this we mean do they

 

 

 

for

 

 

read or xplain signs and

 

 

 

symbols to you?

Not

 

 

 

 

 

This includ s help you

 

 

 

have and help you n d

 

 

 

but don't get

 

 

 

 

 

PIP2 June 2018

20 of 33

Q10c – Extra information - Reading

Tell us more about any difficulties you have when reading and understanding signs,

symbols and written words:

 

 

 

 

• tell us how your condition affects you doing this activity

 

 

 

tell us how you manage at the moment and the problems you have when you can't do

 

this activity

 

 

 

 

tell us how long it takes you to complete this activity

 

 

 

does whether you can do this vary throughout the day? Tell us about good and bad

 

days

 

only

 

 

 

 

 

do your difficulties depend on how complicated the signs, symbols and words are, or

 

how big they are?

 

 

 

 

do you experience other difficulties, either during or after the activity, ike pain,

 

breathlessness or tiredness?

 

 

 

 

tell us about the aids or appliances you need to help y u read

 

 

tell us about the help you need from another person when readi g. This i cludes help

 

you have and help you need but don't get

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

use

 

 

 

 

 

 

 

 

Specimen

 

 

 

 

for

 

 

 

 

 

 

 

 

Not

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

If you need to add more please continue at Q15 Additional information.

PIP2 June 2018

21 of 33

Q11 – Mixing with other people

iUse page 10 of the Information Booklet to help answer these questions.

Tell us about whether you have difficulties mixing with other people.

This means how well you are able to:

• get on with other people face-to-face, either individually or as part of a

 

group

 

 

 

 

 

 

understand how they're behaving towards you, and

only

behave appropriately towards them

 

 

 

 

It includes both people you know well and people you don't know.

 

Tick the boxes that apply to you then provide more information in the Extra

information box.

 

 

 

 

 

 

Q11a – Do you need another

 

Yes

 

 

 

 

 

 

person to help you to

 

No

 

 

 

 

 

 

 

mix with other people?

 

 

use

 

Specimen

 

 

By this we mean:

 

 

 

Sometimes

 

 

• do they encourage you

 

 

 

 

to mix with other

 

 

 

 

 

 

people?

 

 

 

 

 

 

• do they help you

 

 

 

 

 

 

understand how people

 

 

 

are behaving and how

 

 

 

to behave yourself?

 

 

 

This includes help you

 

 

 

have and help you need

 

 

 

but don't get.

 

 

 

 

 

Q11b – Do you find it diffi ult

 

Yes

 

 

 

 

 

 

to mix with oth r

Not

 

 

 

eo le b cause of

 

 

 

No

 

 

 

severe anxiety or

 

 

 

S me imesfor

 

 

distress?

 

 

 

 

 

 

PIP2 June 2018

22 of 33

Q11c – Extra information - Mixing with other people

Tell us more about any difficulties you have when mixing with other people:

tell us about how your condition affects you doing this activity

 

 

tell us how you manage at the moment and the problems you have when you can't

 

do this activity

 

 

 

 

 

do you have behaviours that could put yourself or others at risk?

 

 

does whether you can do this vary throughout the day? Tell us about good and bad

days

 

 

only

 

 

 

do you avoid mixing with other people, some more than others?

 

 

does it take you a long time to mix with other people?

 

 

 

do you experience any other difficulties, either during or after the activity, ike

 

anxiety or distress?

 

 

 

 

 

tell us about help you need from another person when mixi g with other peop e.

 

This includes help you have and help you need but don't get

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

use

 

 

 

 

 

 

 

 

 

Specimen

 

 

 

 

 

for

 

 

 

 

 

 

 

 

 

 

 

Not

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

If you need to add more please continue at Q15 Additional information.

PIP2 June 2018

23 of 33

Q12 – Making decisions about money

iUse page 10 of the Information Booklet to help answer these questions.

Tell us about whether you can make decisions about spending and

managing your money. This means:

 

 

 

 

understanding how much things costs

 

 

 

 

understanding how much change you should get

 

 

managing budgets, paying bills and planning future purchases

 

 

By this we mean:

 

 

 

 

 

 

only

This activity looks at your decision making ability not things like getting to the

bank.

 

 

 

 

 

 

 

 

 

Tick the boxes that apply to you then provide more information in the Extra

information box.

 

 

 

 

 

 

 

 

 

Q12a – Do you need someone

 

 

Yes

 

 

 

 

else to help you to

 

 

 

 

No

 

 

 

 

understand how much

 

 

 

 

 

 

things cost when you

 

 

 

 

 

use

 

 

 

 

 

 

 

 

Specimen

 

 

 

buy them or how much

 

 

Sometimes

 

 

 

change you'll receive?

 

 

 

 

 

• do you need someone

 

 

 

 

 

to do it for you?

 

 

 

 

 

 

 

 

 

• do they need to remind

 

 

 

 

 

you to do it or how to do

 

 

 

 

 

it?

 

 

 

 

 

 

 

 

 

 

• do you need someone

 

 

 

 

 

to help you understand?

 

 

 

 

 

This includes help you

 

 

 

 

 

have and help you n d

 

 

 

 

 

but don't g

t.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

for

 

 

 

 

Not

 

Q12b – Do you n d som one

Yes

 

 

else to help you manage

 

 

No

 

 

your household budgets,

 

 

 

 

ay bills or

lan future

 

 

S metimes

 

 

 

purchases?

 

 

 

 

 

 

 

 

 

 

By this we mean:

 

 

 

 

 

 

 

 

 

• do you need someone

 

 

 

 

 

to do it for you?

 

 

 

 

 

 

 

 

 

• do they have to help you

 

 

 

 

 

manage your bills?

 

 

 

 

 

• do you need

 

 

 

 

 

 

 

 

 

encouraging to do it?

 

 

 

 

This includes help you have and help you need but don't get.

PIP2 June 2018

24 of 33

Q12c – Extra information - Making decisions about money

Tell us more about any difficulties you have when making budgeting decisions:

• tell us how your condition affects you doing this activity

 

 

 

tell us how you manage at the moment and the problems you have when you can't

 

do this activity

 

 

 

 

tell us how long it takes you to complete this activity

 

 

 

does whether you can do this vary throughout the day? Tell us about good and bad

 

days

 

only

 

 

 

 

 

do you experience any other difficulties, either during or after the activity, ike

 

anxiety and distress?

 

 

 

 

tell us about the help you need from another person when making decisions about

 

money. This includes help you have and help you need but do 't get

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

use

 

 

 

 

 

 

 

 

Specimen

 

 

 

 

for

 

 

 

 

 

 

 

 

Not

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

If you need to add more please continue at Q15 Additional information.

PIP2 June 2018

25 of 33

Q13 – Going out

iUse page 10 of the Information Booklet to help answer these questions.

Tell us about whether you can plan and follow a route to another place. Also tell us if severe anxiety or stress prevents you from going out.

This includes planning and following a route to another place using public transport.

 

 

 

 

 

 

 

 

only

This activity doesn't look at your ability to walk which is covered in Question 14,

Moving around.

 

 

 

 

 

 

 

 

 

Tick the boxes that apply to you then provide more information in the Extra

information box.

 

 

 

 

 

 

 

 

 

Q13a – Do you need help from

 

 

Yes

 

 

 

another person to plan

 

 

No

 

 

 

a route to somewhere

 

 

 

 

 

you know well?

 

 

 

 

Sometimes

 

use

 

 

 

 

 

lost?

 

 

 

 

 

 

By this we mean do you:

 

 

 

 

 

 

Specimen

 

 

• need someone to help you plan a

 

 

 

route, or plan it for you?

 

 

 

 

• need to be encouraged to go out

 

 

 

or have someone with you wh n

 

 

 

going out to reassure you?

 

 

 

 

• need help from an assistance dog

 

 

 

or specialist aid, such as a white

 

 

 

stick?

 

 

 

 

 

 

 

 

 

• need someone to be w th you to

 

 

 

keep you safe or stop you gett ng

 

 

 

This includ

s help you have and

 

 

 

 

help you n d but don't get.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

for

 

Q13b – Do you n

 

Not

 

d h lp g tting

Yes

 

to somewhere you don't

 

 

No

 

know well?

 

 

 

 

 

 

By this we mean do you:

 

 

S metimes

 

 

• need to be encouraged

 

 

 

 

 

 

to go out or have someone

 

 

 

 

with you when going out to

 

 

 

 

reassure you?

 

 

 

 

 

 

 

 

• need help from an assistance

 

 

 

 

dog or specialist aid, such as a

 

 

 

 

white stick?

 

 

 

 

 

 

 

 

• need someone to be with you

 

 

 

 

to keep you safe or stop you

 

 

 

 

getting lost?

 

 

 

 

 

 

 

 

• need help using public

 

 

 

 

transport?

 

 

 

 

 

 

 

 

This includes help you have and help you need but don't get.

PIP2 June 2018

26 of 33

Q13 – Going out continued

Q13c – Are you unable to go out because of severe anxiety or distress?

Yes

No

Sometimes

 

 

 

 

 

 

 

 

 

Q13d – Extra information - Going out

 

only

 

 

 

 

 

 

Tell us more about any difficulties you have when planning and following a route:

 

• tell us how your condition affects you doing this activity

 

 

 

 

tell us how you manage at the moment and the problems you have when you can't do

 

 

this activity

 

 

 

 

 

 

tell us how long it takes you to complete this activity

 

 

 

 

 

does whether you can do this vary throughout the day? Tell us ab ut g d a d bad

Specimen

 

 

 

 

 

days

 

 

 

use

 

does whether you can do this depend on where you're g i g?

 

 

 

do you experience any other difficulties, either duri

g or after the activity, like anxi ty

 

 

or distress?

 

 

 

 

 

 

tell us about the help you need from anoth r p rso

when planning and following a

 

 

journey. This includes help you have and help you

d but don't get

 

 

 

 

for

 

 

 

 

 

 

 

 

 

 

 

Not

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

If you need to add more please continue at Q15 Additional information.

PIP2 June 2018

27 of 33

Q14 – Moving around

iUse page 11 of the Information Booklet to help answer these questions.

Tell us about whether you can physically move around

This means how well you can walk and if you need to use aids and appliances to get around.

Tick the boxes that apply to you then provide more information in the Extra

information box.

 

 

 

 

 

only

 

 

 

 

 

 

 

Q14a – How far can you walk

 

Less than 20 metres

 

 

 

taking into account any

 

Between 20 and 50 metres

 

 

 

aids you use?

 

 

 

 

To give you an idea of

 

Between 50 and 200 metres

 

distance, 50 metres is

 

 

 

 

 

 

 

 

 

 

 

approximately 5 buses

 

200 metres or m re

 

 

 

 

 

parked end to end.

 

 

 

 

It varies

 

 

use

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Specimen

 

 

Q14b – Do you use an aid or

 

Y s

 

 

 

appliance to walk?

 

No

 

 

 

Walking aids include:

 

 

 

 

• walking sticks

 

 

 

So ti s

 

 

• walking frames

 

 

 

 

 

 

 

• crutches, and

 

 

 

 

for

 

• prostheses

 

 

 

 

 

 

 

Q14c – Do you use a wheel ha r

 

Yes

 

 

 

or similar d vi

to move

 

No

 

 

 

around saf ly, r

liably

 

 

 

 

 

Not

 

 

 

and r p at dly and in a

 

Some imes

 

 

reasonable time p riod?

 

 

 

 

 

PIP2 June 2018

28 of 33

Q14d – Extra information - Moving around

Tell us more about any difficulties when moving around:

 

 

 

 

• tell us how your condition affects you doing this activity

 

 

 

 

tell us how you manage at the moment and the problems you have when you can't

 

do this activity

 

 

 

 

 

tell us how long it takes you to complete this activity

 

 

 

 

does whether you can do this activity vary throughout the day? Tell us about good

and bad days

 

only

 

 

do you regularly fall? Do you find it difficult to move around on certain ground

 

surfaces?

 

 

 

 

 

do you use a wheelchair? Is it motorised or manual?

 

 

 

 

do you experience any other difficulties, either during or after the activity, ike pain,

 

breathlessness, tiredness, dizziness or anxiety?

 

 

 

 

 

tell us about the aids or appliances you need to use when m vi

g ar u

d

tell us about the help you need from another person when m

vi g ar

u d. This

 

includes help you have and help you need but don't get

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

use

 

 

 

 

 

 

 

 

Specimen

 

 

 

 

 

for

 

 

 

 

 

 

 

 

 

 

Not

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

If you need to add more please continue at Q15 Additional information.

PIP2 June 2018

29 of 33

Q15 – Additional information

Tell us anything else you think we should know about your health conditions or disabilities and how these affect you, that you haven't mentioned already.

• If any carers, friends or family want to provide further information they can do it here

• You don't have to complete this part if you've covered everything in

the form

 

only

 

 

Specimen

use

 

Not

for

 

 

 

 

Continue on separate pieces of paper, if needed. Remember to write your name and National Insurance number at the top of each page and tell us which questions your comments refer to.

PIP2 June 2018

30 of 33

What happens next

Section 4 - What to do now

Also see page 11 of the Information Booklet.

Check you've answered all the questions and sign the declaration in ink

Place this form in the envelope provided so that the address on the back page shows through the window

After we've received your form we may contact you to arrange a face-to-face consultation with a health professional.

This will give you the chance to tell us more about how your health co

dition

or disability affects your daily life. If you've given us enough informatio

, we

might not need to see you.

 

 

 

 

 

If we ask you to go to a face-to-face consultation, you must atte d,

r we

can't decide if you're able to get PIP.

 

 

 

 

 

Specimen

use

Coming to a face-to-face consultatio

 

 

 

 

 

You'll be able to take someone with you. If you ca

't atte d on the date

given, you can contact the health prof ssional to r

arra

ge. Theonlyconsultation

will last about an hour, it's not a full physical xami atio

, but the health

professional will talk to you to understand how your h alth condition or

disability affects your daily life.

 

 

 

 

 

Tell us about any help you (or so eone you bring with you) would need if you

have to go for a face-to-face consultat on.

for

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Not

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PIP2 June 2018

31 of 33

Declaration

We cannot pay any benefit until you’ve signed the declaration and returned the form to us. Please return the signed form straightaway.

I declare that the information I have given on this form is correct and complete.

I understand if I give wrong or incomplete information, my benefit may

 

 

 

 

 

 

 

 

 

only

be stopped and I may be prosecuted or may have to pay a penalty.

 

 

I understand I must promptly tell the office that pays my Personal

 

 

Independence Payment of anything that may affect my entitlement to,

 

 

or the amount of, that benefit.

 

 

 

 

 

 

This is my claim for Personal Independence Payme

t.

 

 

Signature

 

 

 

 

 

 

Date

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

/

/

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

use

 

Specimen

 

Print your name here

 

 

 

 

How the Department for Work and Pensions c llects and uses information

When we coll ct information about you we may use it r any

f ur

 

 

purposes. Th se include d aling with:

for

 

 

social security b n

fits and allowances

 

 

child su

ort

 

Not

 

 

 

 

 

 

 

employment and training

 

 

 

 

financial

lanning for retirement

 

 

 

occu ational and

ersonal pensi

n schemes

 

 

 

 

 

We may get information about you from others for any of our purposes if the law allows us to do so. We may also share information with certain other organisations if the law allows us to.

To find out more about how we use information, visit our website www.gov.uk/dwp/personal-information-charter or contact any of our offices.

PIP2 June 2018

32 of 33

Please return the completed form to this address

Specimen

use

Put the completed form in the e velope provided,

making sure the address shows through theonlyenvelope

window. The envelope do sn’t d a stamp unle you

live outside the United Kingdom. If you’ve access to the

internet, you can get infor ation about Personal

Independence Pay

for

ent by going to the Pe sonal

Independence Pay

ent website at www.gov.uk/pip

Not

33 of 33

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