Environmental Health & Safety

Laboratory Decommissioning Program

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Over the years, a number of laboratories have been vacated by Principal Investigators and were found to contain abandoned equipment, chemicals, biological specimens, sharps, radioactive materials, and a variety of waste materials. Those entering these spaces (cleaning staff, contractors, new occupants, etc.) were placed at risk of exposure to unknown agents. To correct these issues, a Laboratory Decommissioning Program has been implemented.

Periodic changes/updates are made to this program as needed. Ultimately the Principal Investigators and their associated Departments are responsible to adhere to this program. Environmental Health and Safety (EH&S) will construct, implement, and oversee the program.

Initial Date:    August 2002

Revision Date:   October 2003

Minor Revisions:  August 2004

Revision:   October 2008

Revision:   January 2011

Revision:   June 2016

Revision:   May 2018

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1. GENERAL PRINCIPLES
1. The program is applicable for all clinical and research laboratories and auxiliary spaces serving laboratories. This program provides requirements for the removal of non-fixed materials when a user or researcher vacates laboratory space. These can include:
1. Leaving the University of Rochester;
2. Moving to another building or location;
3. Relocating to another laboratory within the same building; or
4. Moving out of an off-campus location.
2. When laboratories are vacated, ALL chemical, radioactive materials, biological materials, sharps, wastes and equipment must be removed and disposed of through University approved waste systems/methods.
3. ALL non-fixed pieces of laboratory equipment must be decontaminated prior to removal and tagged as such before being placed back into service, stored in another location, recycled, or disposed of by Facilities or an outside vendor (See Appendix 1).
4. ALL working surfaces and storage locations must be properly decontaminated and cleaned. Depending upon the materials used in the lab, a NYS approved disinfectant is required for biological materials, Radiacwash for radiological materials, and soap and water for chemical and all other general areas.
5. If a vacated lab does not undergo an EH&S supervised and approved decommissioning, the space and all the materials within it become the responsibility of the Department and/or the new PI/supervisor. Those labs not reoccupied become the responsibility of the Department.
6. The EH&S Laboratory Safety Unit will conduct a final decommissioning inspection to ensure that all areas are properly cleaned to the expectation of this program. The staff can be reached at 275-3241.
2. DEFINITIONS
1. Laboratory Decontamination:  The removal of chemicals, drugs, sharps, biological materials, radioactive substances, supplies, papers/records, non-fixed equipment, and the sanitation (removal of gross contamination) from surfaces. Labs in a decontaminated condition do not pose a recognized hazard to staff, visitors or contractors.
2. Approved Laboratory Decommissioning: An inspection/audit of a lab by EH&S staff to verify the removal of all chemicals, drugs, sharps, biological materials, radioactive substances, supplies, papers/records, non-fixed equipment, and surfaces have been adequately cleaned to remove gross contamination, so the space can be reused by other lab staff or undergo renovations by contractors.
3. Conditional Laboratory Deommissioning: An inspection/audit of a lab by EH&S staff where one or more conditions are still present in the lab but it/they do not pose a hazard to staff or contractors in their present situation.
4. Laboratory (Lab): A laboratory is defined as a place equipped for experimental study in a science or engineering department an dused for testing and analysis using relatively small quantities of chemicals, biologicals, and/or radiological agents. Laboratories include, but are not limited to, research labs, animal procedure rooms, student teaching labs, instrumental/laser labs, clinical labs, environmnental rooms, and associated locations used to house/store research and/or testing materials from labs. Locations that include but are not limited to music labs, sound labs and computer labs are NOT considered labs under this program
5. Principal Investigator (PI):  Consistent with usage in federal grants and contracts, an individual who receives funding to perform a study.  The term PI, in the context of lab decommissioning, can include a co-Principal Investigator (co-PI) and/or a Radioactive Material Permit Holder.  These individuals may also receive funding under the auspices of a non-government funding source. This program impacts those PIs who have laboratories under their direction.
6. Renovation: A renovation is defined as a change in the physical environment of a lab that could include the removal or installation of walls, doors, cabinets, benches, fume hoods, etc. Repairs or replacement in kind are considered general maintenance activities.
7. Supervisors: Clinical laboratories are structured differently than research labs. Rather than PIs heading a lab, clinical labs are under the direction of Supervisors and Managers reporting to a Director. Under this program, the Supervisor/Manager/Director responsibilities shall be the same as that of a PI.
8. Cleaned/Cleaned Out: The removal of all possible gross contamination by use of detergents or disinfectants.
3. RESPONSIBILITIES
1. Deans, Directors, Department Heads
1. Ensure that PI/Supervisors using biological, chemical,radioactive, and/or all other hazardous materials are aware of and follow the procedures contained in this program.
2. See section III. C. for additional responsibilities
2. PI/Supervisor
1. The PI/Supervisor is to notify his/her department, the Radiation Safety Unit, the Laboratory Safety Unit and/or the Environmental Compliance Unit when he/she will be leaving the University or relocating within the University.
2. The PI/Supervisor is to take specific safety measures before leaving or relocating when transferring chemicals to another location and/or disposing of chemicals that are no longer needed.
1. The Environmental Compliance Unit's Hazardous Waste Group (275-2056) should be contacted for specific chemical disposal questions.
2. All chemicals must be removed from the laboratory
1. The Hazardous Waste Group requires the disposal of all unwanted chemicals prior to the actual move date. The PI or designated individual must complete a Chematix waste tag for chemical container for disposal and place the tag on the ocntainer. The Chematix system must then be used to notify the Hazardous Waste Group for a pick up. For large quantities of chemicals, allow up to 14 days for the pickup.
2. Those chemicals to be moved to another lab within the University must be re-assigned and transferred to the new location using Chematix. Please contact the Laboratory Safety Unit for assistance.
3. All chemical shipments to off-site locations must transported in accordance with US Department of Transportation requirements by licensed vendors.
4. The PI/Supervisor is to take specific measures before leaving/relocating for the transfer of biological agents and/or animal tissues.
1. All biologically active materials being transported to off-site locations must abide with US Department of Transportation and IATA Shipping regulations.
2. The University’s Biological Safety Officer (275-3014)can be contacted for appropriate disposal or shipping regulations.
5. The PI/Supervisor must take specific measures before leaving a laboratory for the transfer or disposal of radioactive materials. These measures include:
1. Notify the Radiation Safety Unit (275-3781)4 weeks prior to leaving.
2. Surveying and decontaminating all areas where radioactive materials were used or stored. Equipment in which radioactive materials were used/stored shall also be surveyed and decontaminated. The surveys shall be documented in the laboratory logbook.
3. Transferring any remaining radioactive materials to another University of Rochester Permit Holder with Radiation Safety's consent or making arrangements with the Radiation Safety Unit for disposal. Arrangements can be made through Radiation Safety should there be a need to ship radioactive materials and/or radioactive equipment to an off-site location.
4. Removing and destroying all labels indicating the presence of radioactivity.
5. Reconciling the radioactive materials inventory in the logbook.
6. Canceling dosimetry badges, if appropriate.
6. All labs and storage areas and working surfaces are to be cleaned with an appropriate detergent, disinfectant or decontamination agent based on those materials used in the lab. This includes, but is not limited to, NYS approved disinfectants, Radiacwash, or soap and water.
7. Chemical and/or biological storage equipment (corrosive cabinets, flammable liquid storage cabinets, incubators, refrigerators, freezers, etc.) and non-fixed lab equipment (centrifuges, cryostats, incubators, sonicators, etc.) are to be emptied and cleaned/disinfected prior to being moved or disposed. After the appropriate decontamination activity is completed, attach a copy of the Equipment Decontamination Form (see Appendix 1) to the piece of equipment/apparatus. If the form is not completed and posted on the equipment, it may be assumed that the equipment was not cleaned and may delay moving, repairing, renovation, and disposal activities.
8. All chemicals, equipment, wastes, etc. must be removed from the chemical fume hood counter top and the hood's support cabinet, and the counter top and cabinet cleaned to remove gross contamination. Personnel should schedule work involving the use of a fume hood to allow adequate time to disassemble active chemical research apparatus before cleaning these areas.
9. Biological safety cabinets (BSCs) must be decontaminated by an approved outside certified vendor before moving or disposing of the unit. After the decontamination activity is completed, a copy of the vendor's decontamination form is to be attached to the BSC. If the form is not on the BSC, it may be assumed that the equipment was not decontaminated, delaying moving, repairing, renovation, and disposal activities.
PLEASE NOTE: All BSCs must be recertified by an approved outside vendor once settled in its new location and before being used. This is to ensure the filter or blower was not damaged or dislodged during the moving process.
10. All lab apparatus must be removed from the lab. All papers, rags, empty bottles, boxes, glassware, plastic ware, etc. are to be properly removed/disposed of prior to vacating the lab.
11. All compressed gas cylinders are to be removed and sent back to the supplier prior to the decommissioning of the laboratory. If relocating, all compressed gas cylinders must be capped and transported appropriately to the new location using an approved cylinder cart. If leaving the University or relocating to another building, the PI is to contact the gas vendor to have the company's gas cylinders removed/returned/relocated.
12. The PI will be responsible for all problems discovered and identified during the decommissioning process.  A final approval will not be granted until all issues have been corrected, unless a conditional approval has been granted.
13. Construction and/or demolition crews will not be allowed to enter the areas until the laboratory decommissioning has been approved by EH&S and signage has been posted on the outer door of all spaces.
3. Department / Unit
1. The department/unit is responsible for verifying that the Laboratory Safety Unit and/or the Radiation Safety Unit have been notified at least 4 weeks prior to an investigator moving spaces or leaving the University. This can be accomplished e-mailing questions@safety.rochester.edu or by phone 275-3241.
2. The Department is responsible for any issues or deficiencies not corrected by the PI.   Should the laboratory not be appropriately decontaminated the Department will be held accountable for costs or fees to complete any required decontamination activities.
 
1. These activities may include but not limited to: disposal or decontamination of equipment, chemicals, lab benches, drawers, cabinets, samples and/or all other research or laboratory related hazards identified within the space.
2. The department/unit is responsible to verify items in the departmental common spaces belonging to or associated to the PI have been removed. This includes locations where chemicals, biologicals, and radiological agents may be stored/kept including corridors, linear equipment rooms, the Freezer Farm, common equipment rooms, environmental rooms, freezers, or any other storage location/method.
3. Departmental administrators should contact other lab personnel in their department to assist in decommissioning activities. EH&S can be contacted for other possible outside vendors as a possible solution to assist the lab with particular issues.
 
4. EH&S Radiation Safety Unit (RSU)
1. All permit holders must contact RSU at least 4 weeks before relocating.
2. The PI will be advised on the necessary requirements and precautions to be taken during transfer of radioactive materials.
3. Radiation Safety will collect all radioactive waste containers not being transferred to the new facility.
4. Upon completion of a survey and verification of decontamination by the PI or the department, the RSU will conduct a final confirmatory radiological survey of the facility. The RSU will verify that the equipment used to store or analyze radioactive materials is appropriately decontaminated. The PI will be notified of the radiological survey results. If contamination is identified, lab personnel will be responsible for any additional decontamination necessary. The laboratory will be reevaluated as necessary until decontamination has been confirmed. For information on equipment decontamination, contact the Radiation Safety Unit or refer to the Radiation Safety Manual.
5. EH&S Laboratory Safety Unit
1. The PI or the department must notify EH&S Laboratory Safety Unit at least 4 weeks in advance of the planned lab closure. Upon notification by the PI or the department that the decontamination/clean out is completed, the Laboratory Safety Unit will schedule an appointment to verify the following activities have occurred:
1. All chemical and biological materials have been properly removed, disposed and/or stored;
2. All non-fixed and special in-house equipment/supplies/wastes have been removed; all drawers and cabinets have beeen emptied, fume hoods are free of materials, and biological safety cabinets have been decontaminated;
3. All sharps (needles, razor blades, etc.) have been removed from cabinets, drawers and other surfaces and placed into sharps containers; and
4. All counter tops have been properly cleaned to remove gross contamination.
2. Upon verification that the required decontamination/clean out is complete, the Laboratory Safety Unit will complete a Laboratory Decommissioning Form (see Appendix 2). The Laboratory Decommissioning Form will be posted on the outer door to the lab or decommissioned space.
3. The PI/Supervisor will be responsible for any additional actions that may be needed.  Upon completion of the additional decommissioning activities and a successful evaluation by EH&S, the area will be released for renovation, demolition, construction, and/or reuse to the necessary parties. The Laboratory Decommissioning Form is to remain on the door to the laboratory until the space is reoccupied.
6. EH&S Environmental Compliance Hazardous Waste Group
1. The PI/Supervisor or the department must complete a Chematix waste tag for each chemical container for disposal. The lab must notify the Hazardous Waster Group using Chematix once the hazardous waste is ready for pickup. The lab staff must take the following actions prior to the removal of any hazardous waste:
1. Print and place the Chematix wast tag to each container to be removed from the lab. The tag is specific for that container and allows the Hazardous Waste Group to track the container.
2. Waste containers must be suitable for transport (container compatible with waste, tight fitting caps, the container not over-filled (3/4 filled), and the outside of the containers must be clean).
2. Additional information regarding the disposal of chemicals is available upon request. However, prior to discarding unwanted chemical(s) that are still viable, please work with your department and/or other departments to arrange for the reuse/recycling.
7. Facilities MC/RC Construction Renovation Groups, Campus Planning, Project Management (PPM)
1. For lab renovations, the Project and Planning Management (PPM) or the Facilities manager may utilize outside construction contractors and /or internal personal. If a lab has NOT completed the decommissioning process, construction work must not proceed. Failure to notify EH&S prior to the start of the construction may delay a project. To avoid delays, the Project Manager or Facilities Supervisor is to:
1. Contact EH&S to verify a Laboratory Decommissioning has taken place if the required door signage is not present prior to any planned work or demolition.
2. Have the contractors formulate a work plan for the construction project. Although the laboratory spaces have been cleared of any gross contamination, there could be unseen hazards present that could pose a hazard to contractors. Contractors must utilize appropriate personal protective equipment to minimize potential exposures.
2. Many Facilities Shops are required to perform general maintenance activities in active laboratories.  These activities may include, but are not limited to, repairing gas lines, working on plumbing lines, adjusting fume hood controls, removing or adding cabinets, maintenance of HVAC systems, and painting.  These activities do not require EH&S to perform decommissioning of the space.  However, Facilities must ask the occupants to identify the hazards present in the immediate work location, to have these hazards removed/eliminated, and to terminate work in the immediate space for the duration of the repair/maintenance work.  For example: Should a repair be needed to unclog a waste (sewer) line at a sink, the materials stored in as well as under the sink must be removed, the floor in front of the cabinet cleaned by the occupants (if visibly contaminated), and the occupants cannot use the sink until repaired are completed.
4. EXPECTATIONS

The following photos are provided to demonstrate the expectations of the laboratory decommissioning process in removing potential hazards and cleaning surfaces so the space can be reoccupied or ready for a contractor to renovate:

Before cleaning/decommissioning



Completed decommissioning



As shown, all the non-fixed equipment, chemicals, and materials were removed from the benches, shelves, and drawers. The gas cylinders returned to the vendor, and some of the equipment was recycled (metal and electronics). All bench tops were washed down and disinfected appropriately. This cleanliness is the expectation of this program.

Link to RELATED DOCUMENTS / TECHNICAL SUPPORT / REFERENCES

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

This page last updated 5/9/2018. Disclaimer.