WORKPLACE ASSESSMENT
REQUEST FORM
Personal Details
Please Could You Select Your Preferred Pronouns
?
This helps us address you correctly.
--None--
He/Him/His
She/Her/Hers
They/Them/Theirs
Other
First Name
Last Name
Date of Birth
Mobile Number
Email Address 1
Email Address 2 (optional)
Your Disability, Neurodiversity, or Condition
Work & Assessment Preferences
Work Arrangement
--None--
Office/Site Based
Remote/Home Based
Hybrid Arrangement
How would you like your assessment to take place?
!
If you select Teams/Zoom or Telephone, additional information will be required.
--None--
At my work address
Teams/Zoom
Telephone
How may we contact you to arrange your assessment?
--None--
Phone
Email
Please confirm you have a tape measure available
?
This can help with setup measurements during an assessment.
Yes, I have a tape measure available
Assessment Address
Address Line 1
Address Line 2
Address Line 3
City
County
Postcode
Please list any days/times that might be convenient for your assessment
Employment Details
Company Name
Job Title
Employer/Manager Details
Roles & Responsibilities
Additional Information
Please provide a brief summary of challenges and barriers you are encountering in the workplace as a result of your condition
What IT Equipment do you use in your role?
Computer Specifications
Additional Requirements?
e.g. Access needs, sensory sensitivities, communication preferences
Supporting Documents
Please upload any medical evidence or supporting documentation (if applicable)
Drag & Drop or Click to Upload
File selected
Remove
Consent & Privacy
Are you happy for us to share your assessment info with your Employer?
--None--
Yes - Once I have seen the final draft
No
Please confirm you are happy for us to hold/process your data in compliance with our GDPR/Privacy Policy
--None--
Yes
No
Observations?
--None--
Yes
No
How did you hear about us?
--None--
Employer
Search Engine
Social Media
Event
Friend/Family Recommendation
I confirm the above information is accurate and I consent to being contacted to arrange my assessment.
