Environmental Health & Safety

CHEMICAL HYGIENE PROGRAM

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RESPONSIBILITY

Responsibility for implementing the CHP resides with each department that has a UofR laboratory. EH&S’s Laboratory Safety Unit was given the responsibility to develop the written CHP, implement the “Program”, and act as the University Chemical Hygiene Officer (UCHO). Those departments that have labs must follow the requirements of this “Program”.

Principal Investigators / Supervisors: Principal Investigators (PIs) and supervisors have primary responsibility for the safety of the labs under their jurisdiction. They are responsible for providing leadership and promoting and advancing the laboratory safety culture. The PI/supervisor may delegate safety duties for which he/she is responsible for but can’t relinquish that responsibility/obligation. He/she must ensure that the delegated safety duties are carried out. These responsibilities include:

Appointing a Laboratory Safety Officer (LSO) to oversee safety issues of the assigned spaces and activities under his/her direction. Some departments may wish to designate a single individual as the LSO for the entire department. Such a selection must be endorsed by the department chair and reported to the Laboratory Safety Unit.
Perform risk assessments for hazardous chemicals and procedures prior to conducting the proposed laboratory work.
Selecting and employing engineering controls and laboratory practices to reduce potential exposure to the lowest practical level in accordance with the CHP.
Establishing safe work practices for handling chemicals for all laboratories and projects under their direction by creating site specific operating procedures (SOPs) for the hazardous chemicals or procedures/activities completed by his/her staff members. Generic SOPs for many chemicals/processes can be found on the EH&S web site but must be customized for the activities completed in the lab.
Ensuring that lab members are trained and competent – possess the experience, knowledge, skills and abilities necessary to perform their tasks without injury to themselves or others.
Select personal protective equipment based on the risk assessment or as written in the pertinent site specific SOPs.
Informing lab members of potential hazards associated with the use of hazardous chemicals.
Directing laboratory members attend an EH&S Laboratory Safety Training session annually and providing specific training for lab employees using hazardous chemicals in his/her labs. Site specific training by the PI/supervisor must be provided and documented for lab members upon initial assignment and when new processes/procedures are implemented in the lab.
Completing a chemical inventory for the laboratory locations under his/her direction. Chemical inventories must be updated annually in Chematix, the University’s electronic chemical inventory system.
Investigating and reporting all incidents and near misses, especially to the use of hazardous chemicals.
Ensuring hazardous chemicals are disposed of through the Environmental Compliance/Hazardous Waste Group.
Selecting chemicals and maintaining a record of chemical use for OSHA Carcinogens, IARC Group 1 carcinogens, and reproductive hazards for all personnel under his/her direction.
Making arrangements through EH&S’s Laboratory Safety Unit for any needed chemical monitoring of the laboratory staff and maintaining a record of the monitoring results provided from the Laboratory Safety Unit.
Completing and submitting to EH&S the annual “Declaration of Possession of Regulated Laboratory Chemicals and Biologicals”, a listing of Department of Homeland Security and Select Agents Regulations (biological agents). This form is sent electronically to PIs for review and submission and is also available on the web at http://www.safety.rochester.edu/labsafety/pdf/biochemsurvey.pdf.
Providing emergency contact information on all lab entry doors and on special equipment.
Ensuring proper decommissioning is completed when labs under his/her jurisdiction are vacated. Specific responsibilities for lab decommissioning are listed at http://www.safety.rochester.edu/labsafety/labdecommission/labdecommission.html.
For any high acute/chronic hazard agent, as listed in Section IV.D and XVII.B and C, the PI or designated individual shall complete a SOP for the planned use of the agent prior to its purchase and submit it to EH&S’s Laboratory Safety Unit. EH&S’s Laboratory Safety Unit will authorize the purchase and use of the agent only should they find the SOP and facility acceptable for the agent’s safe use and after federal government approval, if applicable.
Ensuring all lab staff requiring respirators are medically cleared, fit tested annually, provided training on the respirator’s use and limitations, and that respirators are used in accordance with the University’s Respirator Protection Program.
The PI/supervisor is responsible to resolve safety issues identified through the Laboratory Safety Unit’s inspections. Any unresolved issue(s) will be escalated to the department chair and/or the appropriate dean for action.

Laboratory Employees: Laboratory employee responsibilities include:

Completing EH&S Laboratory Safety Training session annually.
Completing laboratory specific safety training.
Planning and conducting laboratory procedures in accordance with the laboratory’s SOPs and the University’s CHP.
Developing and practicing good laboratory practices and personal hygiene habits (examples include frequent hand washing, no eating/drinking in labs, maintaining good housekeeping, not wearing gloves outside of the laboratory, etc.
Wearing clothing and attire appropriate to lab activities. This includes, but is not limited to, wearing pants that cover the entire leg (no shorts, short skirts, or Capri pants), confining long hair, not wearing clothing that has dangling laces/straps or is loose fitting, not wearing dangling jewelry, and wearing only completely enclosed shoes (no sandals, clogs, crocks, high heels or light-weight slipper shoes).
Wearing Personal Protective Equipment when and where required, such as wearing lab coats over street clothes, and eye/face protection, gloves and hearing protection for high noise areas.
Reporting unsafe conditions to the PI/supervisor or the LSO.
Reporting incidents of hazardous chemical exposures and near misses to the PI/supervisor or the LSO using the University’s Employee Incident Report System.
Ensuring chemicals and hazardous wastes are not stored on the floor.
Ensuring hazardous waste is collected at the point of generation and handled in accordance with protocols issued by the University’s Environmental Compliance/Hazardous Waste Unit and adhering to the “Management of Hazardous Materials and Waste”, available at http://www.safety.rochester.edu/envcompliance/pdf/HazardousMaterialsManagement.pdf.
If respiratory equipment is required, ensuring medical clearance is obtained, training on the respirator is received annually, fit testing is completed annually, and using the respirator in accordance with the University’s Respirator Protection Program.
Using compressed gases and cryogenic liquids properly by securing the cylinders in the upright position with a stand or cylinder strap, ensuring caps are placed on cylinders when not in use, and verifying the regulator is approved for the gas to be used for the pressure in the cylinder.
Ensuring at least one other individual is present (never work alone) when using chemicals of moderate, chronic or high acute toxicity.

Laboratory Safety Officers (LSO): The LSO, appointed by the PI/supervisor, will assist the PI/Supervisor in maintaining a high level of safety in their laboratory spaces. The LSO’s responsibilities include:

Ensuring all lab members participate in an EH&S Laboratory Safety Training annually. The link for EH&S training is available at http://www.safety.rochester.edu/labsafety/ihlabhome.html . Alternately, LLE and LLE affiliated lab personnel can participate in LLE’s live or electronic Laboratory Safety Training.
Ensuring all lab members attends lab specific safety training upon initial assignment and when new processes/procedures are implemented in the lab.
Maintaining records of all training the lab staff has completed.
Overseeing the annual documentation for employees who receive medical clearances for the use of respirators.
Enforcing adherence to PPE requirements in accordance with University policies and programs and the laboratory’s SOPs.
Assisting in developing precautions and the implementation of SOPs for chemical hygiene policies and practices within the PI/supervisor’s allocated spaces.
Assisting in the procurement, inventory, use, and disposal of chemicals used in the PI/supervisor’s allocated laboratory spaces.
Serving as a liaison between the department and EH&S.
Reporting unsafe conditions to the PI/supervisor and facilitating the implementation of temporary corrective actions.
Sharing lessons learned and injuries/near miss reports with lab members.
Ensuring the laboratory has a chemical inventory in Chematix, the University’s chemical inventory system, and the lab member has been provided training to access to the SDSs in the system.
Inspecting chemical containers annually for expiration dates, incompatibility and container integrity. Potentially explosive compounds (PECs) are to be checked at least every 6 months.
Ensuring the lab has a spill kit and the spill kit’s contents are full.
Verifying eye wash stations are flushed weekly and the documentation of this activity is maintained.
Verifying Facilities perform periodic shower testing for those showers located within their lab.
Ensuring appropriate lab safety signage and labels are prominently posted, per Section X of this program.
For labs using ductless fume hoods, being responsible for matching the types of filters to the chemicals being used and documenting the filters are being changed out at the prescribed frequency.
Ensuring all biological safety cabinets are recertified annually by an outside vendor.
Ensuring lab members adheres to the requirements for the disposal of hazardous waste, as listed in the “Learners Guide for Responsible Hazardous Chemical Waste Management”.
Overseeing the decommissioning of laboratories should the PI/supervisor leave the University or move to other spaces.
Seeking ways to improve the CHP.

Deans, Administrators, and Department Heads: Deans, administrators, and department heads have ultimate responsibility for administration and compliance with the UofR Personal Protective Equipment Program (PPE), the Respiratory Protection Program, and Hearing Protection Program, the Reproductive Protection Policy (Appendix 2), and the CHP. The administrators shall assist in maintaining an accurate record of laboratory employees to assist in Lab Safety Training compliance, as listed in Section XI.B.
In the case of recalcitrant Principal Investigators or lab groups, disciplinary actions up to and including lab closures will be considered by the department chairs and the University Administration to ensure safe working conditions.

EH&S’s Laboratory Safety Unit Staff: Responsibilities includes broad oversight in the implementation of the CHP and:

Working with PIs, supervisors, administrators and LSOs to develop and implement good chemical hygiene policies and practices.
Providing generic safety training to employees who work in laboratories.
Providing additional training materials to assist the PI/supervisor and the LSO in lab specific training efforts.
Evaluating areas where certain hazardous chemicals are used regularly and determining if monitoring of airborne contaminants is necessary and the frequency at which the monitoring will occur.

Based on the chemical inventory or a request from the lab, a workplace evaluation will be completed to determine the potential of inhalation exposure. This evaluation will ne used to determine the monitoring schedule.
The Laboratory Safety Unit shall retain chemical monitoring reports as prescribed by OSHA.
Any workplace assessment and subsequent chemical monitoring will be reported to the employee monitored and his/her immediate supervisor. Should an over-exposure be determined, a copy of the report will be sent to UHS or SOEM. Recommendations for reducing exposures will also be included in the report.
Requests for the purchase/use of high hazard chemicals (as listed in IV.D and XVII.B and C): The Laboratory Safety Unit shall determine through their workplace assessment whether the SOP and lab’s engineering controls are acceptable. If the control measures are deemed adequate, the Laboratory Safety Unit will authorize the purchase and use of the listed agent. Periodic reassessments shall be completed based on the frequency listed in the appropriate regulation.

Knowing the current legal requirements concerning regulated substances and disseminating this information to the appropriate personnel.
Overseeing periodic laboratory safety inspections and the annual check of fume hoods by EH&S’s Laboratory Safety Unit to ensure compliance with the CHP. The results of the safety inspections will be sent to the PI/Supervisor, the LSO, and, if needed, the Department Chair or applicable Dean for corrective action.
Issuing and sharing advisories or alerts relative to laboratory safety issues PIs/supervisors and to the LSO.
Providing training to Facilities employees on the hazards that may be found in laboratories and making recommendations for controlling the hazards
Seeking ways to improve the CHP and updating the CHP periodically.

Facilities: Facilities personnel have direct control over the laboratory's general and local ventilation systems and utility systems. Facilities responsibilities include:

Informing laboratory personnel in advance of scheduled utility or maintenance shutdowns (gas, water, fume hoods, etc.) through the posting of the notices.
Maintaining local exhaust (fume hoods, slot hoods, ducted biological safety cabinets, etc.) systems to provide the engineering controls necessary to maintain safe laboratory conditions.
The internal blowers of biological safety cabinets are NOT to be serviced by Facilities personnel. Only contractors accredited by the National Sanitation Foundation’s Standard Number 49 Class II Biohazard Cabinetry may work on the internal blowers or filters of these special units. Facilities can perform activities such as the repair of electrical outlets, gas outlet repairs, and light bulbs of these units. Contact EH&S’s Laboratory Safety Unit for additional information.
Informing EH&S’s Laboratory Safety Unit when a major change of an air handler system (HVAC) is contemplated or completed.
Inspecting and flushing safety showers at the frequency specified by EH&S, correcting any identified problems with the showers, and maintaining documentation of these activities.
Inspecting and flushing eyewash units in linear equipment rooms, located in the Cancer Center, Ophthalmology, k-MRB, and MRB-X.
Attending/participating in safety training sessions offered by EH&S.

QUESTIONS or COMMENTS? Contact EH&S at (585) 275-3241 or e-mail EH&S Questions.

This page last updated 7/30/2015. Disclaimer.

Environmental Health & Safety

CHEMICAL HYGIENE PROGRAM

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