UC Irvine Ergonomic Evaluation Request

Use this form to request an on-site Office and Computer, Laboratory, or Manual Material Handling evaluation.  In this one-on-one evaluation, work areas and job processes will be observed to identify risk factors.  The evaluation will take approximately 45 minutes. Visit our website for more information on Ergonomics and other EH&S programs.

* Required fields

* Employee Name:
* E-mail Address:
* Work Phone:
* Department:
* Building and Room #:
* Job Title:
* Union/Bargaining Unit:
* Supervisor:
* Supervisor's Work Phone:
* Supervisor's E-mail:

* Type of Evaluation:

* Reason for Request:
New Employee
New or Additional Workstation/Job Process
Worstation Improvement
Discomfort (Please specify and describe your discomfort in the Additional Comments section. )

Additional Comments: