Work Related Stress Questionnaire

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Find out if you may be eligible to make a claim for stress at work by completing our Claim Questionnaire.

Our specialist team will review every enquiry made and let you know how we may be able to help you further.

Name

Tel

Where is/was your place of work

What is/was your job role

Roughly when did you first experience symptoms of stress at work?

What were the main symptoms you noticed?

Were there any non work related causes of your stress around the same time?

Did you speak to your GP (or other medical professional) about the symptoms of stress?

If you have spoken to your GP (or other medical professional), when approximately did you first do this?

Have you been prescribed any medication for your stress symptoms or been referred for any talking therapies (e.g. counselling, CBT etc)?

What do you believe has caused you the stress at work? E.g. too much work with a lack of support, bullying, harassment, mishandled policies/procedures.?

If you believe you have suffered bullying or harassment at work, please provide an overview timeline of what has happened and approximately when.

If you believe you have suffered with too much work with a lack of support, please detail what level of work you believe you should have (or should have had) and what level you were being required to manage.

Did you complain to anyone about the problems you were having or the symptoms of stress you were experiencing?

If so, please confirm to who you complained, roughly when you first complained, whether your complaint was verbal or in writing, and what response you received (if any)? If you made your complaint in writing, please attach a copy of this (together with a copy of any response) to us when you submit this questionnaire.

Have you had any time off work because of the stress?

If so, how may periods of absence have you had and roughly what dates were you absent from work with stress?

If you have had more than 1 period of absence from work with stress, did your employer hold any return to work meetings with you or make any referrals to Occupational Health for advice? If you have any Occupational Health reports, please attach a copy of these to us when you submit this questionnaire.

If you have had more than 1 period of absence from work with stress, were any changes made by your employer on your return to work to help and/or support you? If so, please confirm what these changes were and whether they did help to alleviate your stress symptoms.

Have you ever had any previous mental health difficulties previously? If so, was your employer aware of these?

Is there anything else you think we should know so that we can assess your case?