Working Well Norfolk – Participants Form

Please fill in the form below ensuring that all the “Required” boxes are complete. This information is needed for us to assess your eligibility for the programme.

Section 1 – Eligibility and background

Can you confirm that you are a resident of Norfolk and are not on any other employment programme or receiving employment support except from Job Centre Plus?(Required)

Yes

Which of the following best describes your current circumstances? (Select One option)(Required)

You have been employed for at least 6 months (min 7hrs a week) and are either off sick or struggling in the workplace due to a disability

You are out of work and require support to move into sustainable employment

Are you 16yrs or over?(Required)

Yes

Which of the three eligible groups applies to your current circumstances?(Required)

Mental health

Physical Disability

Individuals who experience other long-term sickness or disability

Section 2 – Your details

Name(Required)

Title First Name Last Name

Date of birth(Required)

National Insurance Number (if known):

Email(Required)

Enter Email Confirm Email

Phone(Required)

Address(Required)

Address Line 1 Address Line 2 Town/City Post Code Country

Gender(Required)

Do you have a birth certificate or passport?(Required)

Yes

Where did you hear about us? Please select and specify details in the box at the bottom(Required)

Please specify name or location of the organisation / referral source(Required)

Your Personal Data

Seetec is committed to data security and the lawful , fair, and transparent processing of personal data. We will process the personal information you provide only for the purposes of joining the Working Well Norfolk Programme.

Your data will be retained only for as long as necessary to complete this process, and if you decide that you no longer wish to join the programme or your referral is not approved, your data will be deleted from our systems within 30 days of notification.

We may retain anonymised data (data which cannot be associated with you) for statistical and reporting purposes.

For further information on how Seetec processes personal data, please see our privacy policy.

Working Well Norfolk – Participants Form

Section 1 – Eligibility and background

Section 2 – Your details

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