Barry Bennett technical 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 telephone no:*

Referrer / assessor e-mail:*

Assessee details

Name:*

Address or location to be assessed at:*

Assessee telephone no:

Assessee e-mail:

Sex:*


Type of assessment required:*




Relevant background information relating to disability / current issues:

Any assistive technology currently being used - please include specification if appropriate:

Assistive technology you would like us to demonstrate on-site - please state range of products / specific items:

Duration of studies remaining, including any part years:

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