Ergonomic Evaluation Request

UCLA Health System

Ergonomic Evaluation Request

Any UCLA Health System staff member, including those recently hired, may submit this form.

Requested By (Please check one)

Employee Supervisor

Occupational Health

Employee Name (Last, First) ,

Employee email address

EID# Today’s Date

Work Phone Number/Ext. Best Alternate Number

Department Bldg Room#

Supervisor Name Supervisor Ext.

Although a Supervisor’s approval is not required to request a workstation evaluation, it is recommended that you notify them of this request. There is no charge to the department for the ergonomic evaluation. Please fax the completed request form directly to the Safety Office below or email to

Thank you.

David Wilson

Safety Specialist

Health System Safety Department

Phone 310-794-6392

Fax 310-794-5846