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
Supervisor Name
Room#
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 dwilson@mednet.ucla.edu
Thank you.
David Wilson
Safety Specialist
Health System Safety Department
Phone
310-794-6392
Fax
310-794-5846