bb/form/1a/Oct2015
Application for a blue badge (further assessment form)
Please find attached an application form for a blue badge. This form is for people who have a
permanent and substantial disability that is likely to last at least three years and which means that
they cannot walk or have very considerable difficulties in walking. It cannot be used by people who
are automatically eligible for a blue badge. If this form does not apply to you, please look on
Nottinghamshire County Council’s website for the correct form, or ring our Customer Services Centre
and ask for the correct form to be sent to you. If you have access to the Internet, please remember
that you can apply for a blue badge online.
Please be aware that medical conditions such as asthma, Crohn’s disease/incontinent conditions,
autism, Myalgic Encephalomyelitis (M.E) and other mental/cognitive/intellectual disabilities are not in
themselves a qualification for a badge; people with these conditions may be eligible for a badge if
they are unable to walk or have very considerable difficulty in walking. Eligibility is not determined by
the presence of any particular diagnosis or condition.
The application form asks you to describe the nature of your disability and to give an estimate of the
maximum distance you can walk without assistance or severe discomfort. It can be difficult to
accurately work out the distance you can walk. There are several things that can help you:




Ask someone to walk with you and pace the distance you walk
The average adult step is just under one metre
The average double-decker bus is about 11 metres long
A full-size football pitch is about 100 metres long.
If you still find it difficult to work out the distance you can walk in metres, please tell us:



The number of steps you can take, and how long, in minutes, it would take you to walk this
distance
About your walking speed
The way that you walk, for example, shuffling or small steps etc.
We may ask you to have a face to face mobility assessment with an independent health professional,
such as a physiotherapist or occupational therapist, in order to decide whether you meet the eligibility
criteria.
If the effort required to walk presents a danger to your life, or would be likely to lead to a serious
deterioration in your health, please give details in section 2 of the form. You will need to show that
you cannot walk very far because of the danger to your health and that the danger is a direct result of
the effort required to walk. This criterion is for people with serious chest, lung or heart problems who
may be physically able to walk normally.
People with epilepsy will need to show that any fits are brought about by the effort required to walk.
Please read the following notes before you complete the application form. Your application will be
delayed if you do not provide all the information that we ask for.

If you are applying for a Blue Badge on behalf of someone under the age of 16, please provide their
Child Registration Number. This can be found on Child Benefit documentation.
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
Proof of your identity and address must be a photocopy of one of the documents listed in section 1.
The photocopies will be destroyed at the end of the application process. Please do not send original
documents to us as we cannot be liable for any loss or damage.

You must submit a passport sized photograph of yourself or of the applicant if you are applying on their
behalf. The photograph must be of the same standard as those used for passports and must have been
taken in the last month. It must be of the applicant’s full face and no-one else should be in it. The
photograph will be placed on the back of the badge and will not be visible when the badge is being
displayed in the vehicle. Photographs that do not meet the correct standard will be returned to you.

You must send a cheque or postal order for £10 made payable to Nottinghamshire County Council. The
badge will not be issued to you until the fee is paid.
Wherever you live in the county, please send your completed form back to:
The Blue Badge Team
Nottinghamshire County Council
Customer Service Centre
PO Box 9320
Nottingham NG15 5BL
Please ring our Customer Services Centre on 0300 500 80 80 for all queries about your application.
Opening times: Mon-Fri 08.00-20.00 / Sat 08.00-12.00. We aim to deal with your application as
quickly as possible. Please do not ring us unless you have been waiting for more than 8 weeks for
your badge to arrive.
Please do not send these notes back to us when you return your form.
You can use this space for your own notes.
Date form returned to the Blue Badge Team: …………………………………..
bb/form/1a/Oct2015
BLUE BADGE APPLICATION (further assessment form)
Telephone enquiries: 0300 500 80 80
Monday to Friday: 8am-8pm
Saturday: 8am-12pm
Please complete all relevant sections of the application form and supply the appropriate documents to
confirm your address, identity and evidence of eligibility. You will also need to provide a recent
passport photograph and a £10 fee. The local authority may refuse to issue a badge if you do not provide
adequate evidence that you meet the eligibility criteria.
Section 1 – Information about you
If you are completing the form on behalf of an applicant who is under 16 or who is unable to complete the form
themselves, please provide their details in appropriate sections and sign the form on their behalf.
Application for:
Title:
☐New Badge
Mr ☐
Mrs☐
☐ Reapplication for existing badge
Miss
☐
Expiry date: ………/..……/..……
Ms ☐
First name:
Surname:
Surname at birth:
Gender:
Male ☐
Date of birth:
DD
Place of birth:
☐☐
Female ☐
MM
☐☐
YYYY
☐☐☐☐
Town:
Country:
National Insurance / Child Registration number:
☐☐ ☐☐☐☐☐☐ ☐
Address:
Postcode:
Home tel:
☐☐☐☐ ☐☐☐
Mobile:
Email:
Previous address (if you have moved in the last 3 years):
Postcode:
☐☐☐☐ ☐☐☐
Do you currently hold a Blue Badge, or have you held a Blue Badge before?
If yes,
Which local authority issued you with the badge?
What is the serial number on the badge?
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Yes ☐
No
☐
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Proof of address
We need to check that the applicant lives in Nottinghamshire before we can process your application. Please
enclose a photocopy of one of the following, bearing the name and address of the person that the badge is
for:
Current Council Tax bill bearing my name and address, dated within the last 12 months
A copy of a valid driving licence
Benefit letter from the DWP dated within the last 12 months
Pension letter from the Pension Service dated within the last 12 months
If under 16, a confirmation letter from the school that the child attends
Proof of identity
We need to check the applicant’s identity to stop fraudulent applications for a badge. Please enclose a
photocopy of one of the following as proof of the applicant’s identity:
Birth certificate / adoption certificate
Valid driving licence
Passport
Medical card
Bus pass
Section 2 – Please describe the difficulties you have with walking
Please note that you will only qualify for a blue badge if you, or the person on whose behalf you are applying,
are over two years of age and have a permanent and substantial disability which means you are unable to walk
or have very considerable difficulty in walking.
Q1. Please describe all your medical conditions or disabilities and say how they affect your ability to
walk: please include the medical terms if you know them:
Q2. Your general walking ability: Please answer yes or no to each of the following statements.
I am unable to walk at all and use a wheelchair all the time
Yes
No
I am able to walk, but use a wheelchair for trips outside the home
Yes
No
I am able to walk, but struggle with longer distances or hills
Yes
No
I am able to walk around my home, but I am unable to climb stairs
Yes
No
I am able to walk around the supermarket to do my own shopping
Yes
No
I am able to walk and can use public transport for some of my local trips
Yes
No
I am able to walk well, including recreational walks
Yes
No
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Q3. Please tick the box which best describes the way you walk: Please tick one box only.
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Normal - no specific problems with walking
Adequate – e.g. you walk with a slight limp
Poor – e.g. you walk with a heavy limp, a shuffle, or have problems with balance
Extremely poor – e.g. you drag your leg, stagger, swing through 2 crutches or need
physical support
I am unable to walk at all
Other (please give details):
Q4. Are you able to walk outside without help from another person?
Yes
No
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Yes
No
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If no, please tell us why:
Q5. Do you use any of the following?
If yes, please tick whichever options apply to you
1 Walking Stick
2 Walking Sticks
1 Elbow Crutch
2 Elbow Crutches
Walking Frame
Rollator
Wheelchair
If you use a walking aid, please identify how you obtained them:
Prescribed by an occupational therapist
Purchased by me
or physiotherapist
Other (please describe below):
Q6. Do you anticipate your conditions/disabilities will improve in the next 3 years?
Yes
No
Yes
No
I am awaiting treatment for the conditions which affect my walking
(please give the date of your treatment if known)
Yes
No
I am recuperating from surgery in relation to the conditions that affect my walking
(please give the date of your surgery)
Yes
No
If yes, please say why:
I am awaiting surgery in relation to the conditions which affect my walking
(please give the date of your surgery, if known)
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Please give details of the healthcare professionals, or specialists (including your GP) who have been treating
you in relation to the conditions which affect your walking:
Name
Job title
Hospital / Health Centre
Telephone Number
Walking Ability - Breathlessness
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Q7. Please answer yes or no to each of the following statements:
I am able to walk, but I get breathless if I walk for more than a few minutes
Yes
No
I am troubled by shortness of breath when hurrying on level ground or
walking up a slight hill
Yes
No
I get short of breath walking with other people of my own age on level
ground
Yes
No
I have to stop for breath when walking at my own pace on level ground
Yes
No
I get too breathless to leave my home, or after dressing
Yes
No
I have been prescribed oxygen so that I can carry out daily activities
Yes
No
If yes to any of the above, what are the medical conditions that cause your breathlessness?
Walking Ability - Pain
Q8. Do you find it painful to walk for more than a few minutes?
Yes
No
If yes, is the pain:
Constant
When walking
After walking/at rest
How much pain do you experience when not walking?
(0=no pain, 10 = the worst pain imaginable)
0
1
2
3
4
5
6
7
8
9
10
7
8
9
10
How much pain do you experience when you are walking?
(0=no pain, 10 = the worst pain imaginable)
0
1
2
3
4
5
6
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Are you currently taking any medication for pain relief?
Yes
No
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If yes, please identify below.
Medication
Dosage
Frequency
Q9. Are you seeking specialist treatment or attending clinics for pain relief?
Yes
No
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If yes, please identify below.
Surgeries / courses of treatment / specialist clinics:
Dates you received this
treatment
Walking ability – distance, speed & time
Q10. Please identify how far you are able to walk before you feel severe discomfort or have
to stop, and how long it takes you to walk this distance. Please state the distance in
either metres or yards. Please see the guidance notes at the end of this form if you need help
with identifying distances.
I am able to walk:
Metres/ yards before I feel severe discomfort and it takes me
minutes to walk this distance.
I am able to walk:
Metres/yards before I have to stop and it takes me
minutes to walk this distance.
Where are you able to walk comfortably to from home? (Please give the name of a
road or a place)
How long does this journey take you?
minutes
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Q11. Are you able to continue walking after a short rest?
Yes
No
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If yes, roughly how long are you able to walk for in total?
minutes
Section 3 - Consent to a mobility assessment
You may be asked to have a mobility assessment with one of our assessors. Please tick the following
statement to say that you agree to this. If you are asked to have a mobility assessment and you either do not
agree, or do not attend, we will not be able to continue with your application.
I understand that I may be required to undertake a mobility assessment with a healthcare
professional that is independent of my existing care and treatment, in order to determine my
eligibility for a Blue Badge.
If you are asked to have a mobility assessment, it will be at one of the following places. Please tick all the
places that you are able to travel to:
Arnold – Civic Centre, Arnot Hill Park, Nottingham NG5 6LU
Retford – Bassetlaw District Council, 17B, The Square, Retford, Nottinghamshire DN22 6DB
Worksop – The Library, Memorial Ave, Worksop, Nottinghamshire S80 2BP
Beeston – Highfields Fire Station, Hassocks Lane, Beeston, Nottingham NG9 2GQ
Newark – Bridge Sure Start Children’s Centre, Lincoln Rd, Newark, Nottinghamshire NG24 2DQ
Hucknall – Butler’s Hill and Broomhill Sure Start Children’s Centre, Broomhill Road, Hucknall, NG15 6AJ
Mansfield – CISWO Berry Hill Ln, Mansfield NG18 4JR
Please tick this box if you get, or have had, social care support from the Council, for example, aids and
adaptations to your house. If you get social care support from the Council, we will check our social care
records to help to decide about your eligibility for a badge. This may avoid the need for a mobility
assessment.
Section 4 – Further information in support of your application
Please identify any other medications you are taking in relation to your medical conditions.
Please continue on a separate sheet or enclose an old prescription if necessary.
Medication
Dosage
Frequency
Please add anything else that you think is relevant in support of your application for a Blue Badge.
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Section 5 - Mandatory declarations
Please read the following declarations. They underpin the terms of applying for a blue badge. In order for us
to process your application you must agree to and tick all the declarations. If you do not tick them all we
will be unable to accept your application for a blue badge.
I confirm that, as far as I know, the details I have provided are complete and accurate. I realise
that you may take action against me if I have provided false information in this application
form.
I confirm that the photograph I have submitted with my application is a true likeness of me.
I confirm that I do not currently hold a Blue Badge issued by a different local authority.
I understand that I must not hold more than one valid Blue Badge at any time.
I understand that I must promptly inform my local issuing authority of any changes that may
affect my entitlement to a badge.
I understand that you will deal with all documents relating to this application in line with the
Data Protection Act 1998, and you may share them with other local authorities, the police and
parking enforcement officers to detect and prevent fraud.
I understand that the medical information I have supplied to support this application is deemed
to be “sensitive personal data” and I consent to its disclosure only to a third party who is
responsible for the operation and administration of the Blue Badge scheme and other
government departments or agencies, to validate proof of entitlement.
I agree that, if my application is successful, I will not allow any other person to use the badge
for their benefit and I agree that I will use the badge in accordance with the rules of the scheme
as set out in the “Blue Badge scheme: Rights and Responsibilities” booklet which will be sent
to me with the badge.
Section 6 – Optional declaration
You may wish to tick this optional declaration to improve the service you receive from us. In doing so, you will
be providing specific consent to the Council to allow us to share information about you with relevant
departments and service providers within the authority.
I agree to the disclosure of the information included in this form to other council departments/
service providers so that I can be informed about other council services that may be of benefit
to me.
Your signature against the declarations in sections 5 and 6 of the application
form - all applicants must sign and date the form prior to submitting it. We may refuse to issue a badge if we
have reason to believe that the applicant is not who they claim to be or that the badge would be used by
someone other than the person to whom it has been issued.
Your signature:
Date of application:
DD
MM
YYYY
If you are signing on behalf of someone else please give your name and your relationship to the applicant:
Name:
Relationship
Please send correspondence relating to my application in large text (this declaration is related to
correspondence sent by the Blue Badge Team only).
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