Ergonomic Evaluation Request by zPI7RLT


									                                   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

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