Face-to-face Online
Details of workstation environment (select one of the following options below): Hot desking Works from home Works from a variety of geographical locations Designated workstation Works from vehicle Customer facing workstation
Current workstation setup (select all that apply): Desktop computer Standard mouse and / or keyboard Assistive software Laptop Specialist mouse and / or keyboard Specialist chair
What does the employee’s job role involve? (select all that apply): Computer data input using Office and internal applications Hand-written note taking Manual lifting / carrying Customer face-to-face interaction Telephone work Attends meetings Expected to travel within job role
What type of condition relates to this referral (select all that apply): Physical: e.g. mobility or dexterity condition Audio: e.g. hearing Neurodivergent e.g. AS, SpLD, Dyslexia Mental health Visual Other
* If you ticked ‘Hearing’ please advise whether the employee wears a hearing aid?: Yes No
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