Barry Bennett ergonomic assessment form

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Please complete the form below to request an ergonomic assessment.

Fields marked with an asterisk (*) are required.

Referrer details

Assessment centre:*

Referrer / assessor name:*

Referrer / assessor tel:*

Referrer / assessor e-mail:*

Assessee details


Address or location to be assessed at:*

Assessee telephone no:*

Assessee e-mail:*


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.

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:

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