Barry Bennett Ergonomic Assessment Form
Please complete the form below to request an ergonomic assessment.
Fields marked with an asterisk (*) are required.
Referrer / assessor name:*
Referrer / assessor tel:*
Referrer / assessor e-mail:*
Address or location to be assessed at:*
Assessee telephone no:*
prefer not to disclose
Other (please state below)
Please summarise the funding body approved medical evidence below
Will the end user be using a laptop or 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.
Foot Rest (if required)
Laptop posture pack (includes laptop stand and basic keyboard and mouse)
Monitor arm (desktop PCs)
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, including any part years:
*For security purposes, please type the letters in the image.