Barry Bennett Ergonomic Assessment Form

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.

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:

Please complete the form below to request an ergonomic assessment For assessments for your employees please use this form

Referrer details

Assessee details

Please complete the form below to request an ergonomic assessment
For assessments for your employees please use this form