Barry Bennett Ergonomic Assessment Form

Please complete the form below to request an ergonomic assessment.

Fields marked with an asterisk (*) are required

Referrer’s Details

Company Name /Assessment Centre:*

Referrers /Assessors Name:*

Referrer / Assessors Tel:*

Referrers / Assessors E-mail:*

Assessee’s Details

Name:*

Address Or Location To Be Assessed At:*

Assessee’s Telephone No:

Assessee’s E-mail:

Sex:*

Male Female

Funding Body:*

Date Of Birth or CRN Number:*

Weight:

Height:

Reason for Assessment:*

New Workstation Experiencing Discomfort Diagnosed Condition Other

Ergonomic Equipment Required

Medical History:

Diagnosis:

Symptoms:

Current Treatment:




A	Buttock to top of shoulder	Cm

B	Buttock to centre of lumbar curve	Cm

C	Under elbow to buttock	Cm

D	Back of buttock to behind knee	Cm

E	Under knee to base of foot (in shoes)	Cm

F	Height of Desk (To Top of Surface)	Cm

G	Width Across Hips	Cm

PLEASE MAKE SURE ALL MEASUREMENTS ARE TAKEN WHEN IN THE SEATED POSITION

About You (please tick where appropriate)

Are you a touch typist?	Yes	No
Which is your dominant hand?	Right	Left
Do you use a mouse?	Yes	No
Do you work full/part time?	Full	Part

Any other further information:

For security purposes, please type the letters in the image.