Barry Bennett ergonomic assessment form

Back to - DSA Assessors

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:*
Male
Female
Prefer not to disclose
Other (please state below)

Other
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?
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.

Ergonomic chair
Foot Rest (if required)
Workstation
Laptop posture pack (includes laptop stand and basic keyboard and mouse)
Monitor arm (desktop PCs)
Document holder
Ergonomic keyboard
Ergonomic mouse
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 remaining, including any part years:

nine six three

Please enter the numbers as digits below (without spaces):

Your message was successfully sent!

Our Company

About us
Important information
Complaints procedure
Careers
Privacy policy
Terms and conditions
Charity news
News
Offsetting Our Carbon Footprint
Carbon reduction plan
Accessibility statement

Contact info

[email protected]

01204 534 311

Barry Bennett Ltd
Units 47 & 48, Waters Meeting Business Park
Britannia Way
Bolton
BL2 2HH