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EHS Service Request Form

Please complete the form below to schedule an EHS Service Request
Site *This question is required.
This question requires a valid email address.
This question requires a valid email address.
EHS Program *This question is required.
If this is an emergency, please call #36 (on-campus) or 911 (off-campus)
All employees requesting ergonomic assistance are asked to complete Healthy Working, a web-based ergonomics training and risk assessment survey. BruinErgo must be completed prior to having an on-site evaluation.

Research-based and UCLA campus departments, please visit for assistance. *This question is required.
Have you completed Healthy Working?
Specify Referral
Onsite Evaluation
Security Check