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Barry Bennett ergonomic assessment form
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DSA Assessors
Please complete the form below to request an ergonomic assessment
For assessments for your employees please use
this form
Fields marked with an asterisk (*) are required.
Referrer details
Assessment centre:*
Referrer / assessor name:*
Referrer / assessor tel:*
Referrer / assessor e-mail:*
Assessee details
Name:*
Address or location to be assessed at:*
Assessee telephone no:*
Assessee e-mail:*
Gender:*
Please state gender
Male
Female
prefer not to disclose
Other (please state below)
Funding body:*
Please summarise the funding body approved medical evidence below
Please indicate if the student has difficulties with any of the following (please tick).
Moving from a sitting to a standing position (uses chair to assist)
Core stability/balance issues
Moving a chair independently whilst seated
Transfer to a wheel chair (powered or manual)
Will the end user be using a laptop or desktop PC?
Will the end user be using a laptop or desktop PC?
Laptop
Desktop PC
Ergonomic equipment you would like us to assess for
(please tick any that are appropriate).
Please do not duplicate any items the student has previously been assessed for or that have been included in any pending NAR.
Ergonomic chair
Foot Rest (if required)
Workstation
Laptop posture pack (includes laptop stand and basic keyboard and mouse)
Monitor arm (desktop PCs)
Document holder
Ergonomic keyboard
Ergonomic mouse
Wrist or arm supports
Rolling laptop carry case
Any other ergonomic equipment for us to assess for, or points we need to consider during this assessment
Approximation of height and weight:
Duration of studies remaining, including any part years:
*For security purposes, please type the letters in the image: