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WorkWell Newcastle Referral Form

WorkWell - delivered for the NHS, reducing health barriers to work. Please fill in your details below and one of our team will be in touch shortly. If you have any problems, contact us on telephone 0191 2774125 or email us at: Workwell@newcastle.gov.uk

Eligibility Criteria

To be eligible for WorkWell, a person must:

  • Be aged 18 or over, live in a Newcastle postcode and be eligible to work in the UK

They must also have a health condition affecting their ability to work, for example:

  • Struggling to stay in work due to their health
  • Currently off sick
  • Recently unemployed (within the last 6 months) due to their health

1: Referral partner information  
   
Referral partner information
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2: Forename 
Forename must be provided
3: Surname 
Surname must be provided
4: Address line 1 
Address line 1 must be provided
6: Postcode 
Postcode must be provided
7: Gender 
Gender must be provided
8: Ethnic Origin 
Ethnic Origin must be provided
9: Email address 
Email address must be provided
11: Date of Birth 
Date of Birth must be provided
12: NHS Number 
   
NHS Number
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13: Employment Status 
Employment Status must be provided  Select only one Employment Status 
Employment Status
14: Disability or Health problem 
   
Disability or Health problem

* Data Protection Notes


This project is delivered by Newcastle City Council in partnership with Connected Voice and funded by the NHS North East and North Cumbria Integrated Care Board for the (NENC ICB)

The data we collect about you and why:
We will collect information about you, your health and wellbeing, and your employment status. This helps us understand your needs, and how the service has or has not made things better for you. The information we request is collected only with your consent.

How we use your data:
All personal information collected about you will be stored securely and treated in accordance with the UK General Data Protection Regulation (UK GDPR). Your information will be stored electronically and will only be used for the purpose of performance management of this contract and for monitoring and evaluating the impact of the programme. This includes sharing information we collect with Connected Voice and ICB NENC.
We will collect and process your personal data to help assist with understanding the impact of the Workwell programme. The City Council, Connected Voice and ICB NENC will only retain data for a period necessary to achieve project objectives and meet legal requirements.
For further information about the data collected within Workwell, or to request access to or removal of your data, contact workwell@newcastle.gov.uk.

Before your data is shared with partner organisations (ICB NENC and Connected Voice), your identifiable information such as name, address and contact details will be removed. Other information, such as your NHS Number, Date of Birth, Gender, Ethnicity, and general information relating to your health will be retained for project purposes.
Do you agree to the data protection terms and conditions?
Client:
Date: ......................... Signed: .......................................
Caseload:
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