Referrer details
Referring Institution:
*
Referrer name:
*
Referrer tel:
*
Referrer e-mail:
*
Assessee details
Assessee name:
*
Address or location to be assessed at:
*
Assessee telephone no:
*
Assessee e-mail:
*
Please state prefered format
Prefered format:
*
Remote
Face to face
Please state gender
Gender:
*
Male
Female
Prefer not to disclose
Other (please state below)
Other:
Please provide any relevant background information / reason for this assessment:
Please indicate if the staff member 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)
Ergonomic equipment you would like us to assess for
(please tick any that are appropriate).
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:
Purchase order reference:
Please upload your purchase order:
PDF and word files allowed. Maximum size 2MB.
Additional file upload:
PDF and word files allowed. Maximum size 1MB (each).
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