Breadcrumbs

Evaluation Request

All UCLA campus employees are encouraged to take BruinErgo, a web-based ergonomics training and risk assessment survey. Please indicate your reason for contacting the Ergonomics Program by checking the appropriate box below. Multiple sections available.

Employees referred to this program by Occupational Health (OHF) or Workers' Compensation (Insurance and Risk Management, Sedgwick CMS) must submit their contact information and indicate the referral source to be contacted within 48 hours.

UCLA Employee ID(*)
Invalid Input

9 Digit Employee ID#

First Name(*)
Please let us know your name.

Last Name(*)
Invalid Input

Job Title(*)
Invalid Input

Building and Room Number
Invalid Input

Physical Address
Invalid Input

(For Off Campus Location)

Your Email(*)
Please let us know your email address.

Phone(*)
Invalid Input

Department
Invalid Input

Manager First Name(*)
Invalid Input

Manager Last Name(*)
Invalid Input

ManagerEmail(*)
Invalid Input

Manager Phone
Invalid Input

Reason for contacting ergonomics

Invalid Input

Comments
Please let us know your message.

Captcha
Captcha
  RefreshInvalid Input