Laboratory Safety Manual - Chapter 02: Laboratory Safety Plan

Title

Laboratory Safety Manual - Chapter 02: Laboratory Safety Plan

Introduction

This chapter provides detailed instructions for completing and updating the various schedules of a Laboratory Safety Plan. The Laboratory Safety Plan is a required document that outlines specific conditions, hazards, and controls in your laboratory spaces.

Table of Contents

  1. Introduction
  2. Schedule A: Laboratory Project Information
  3. Schedule B: Hazardous Chemicals & Equipment
  4. Schedules C & D: Radioactive Materials & X-Ray Equipment
  5. Schedule E: Laser Equipment
  6. Schedule F: Biological Hazards
  7. Schedule G: Recombinant DNA
  8. Schedule H: Use of Transgenic Animals or Plants
  9. Schedule I: Shipping
  10. Schedule J: Clinical
  11. Appendix 2-A: Sample Laboratory Floor Plan
  12. Appendix 2-B: Online Chemical Inventory Instructions

Introduction

Laboratory Safety Plans are a key element of the Chemical Hygiene Plan. The purpose of the Laboratory Safety Plan (LSP) is to provide all lab workers with safety information specific to the laboratory in which they work. Annual communication of LSP contents to laboratory personnel by the Principal Investigator provides the minimum workplace-specific training required by the OSHA Laboratory Standard.

This chapter describes the required information to include in an LSP. The Laboratory Safety Plan web application allows a Principal Investigator to submit his or her LSP online, directly into the EHS database.

Preparing a Plan

Each Principal Investigator is required to prepare a Laboratory Safety Plan to supplement the Laboratory Safety Manual. Complete a separate LSP for each building in which you have laboratory space. Laboratory space is considered any location in which you use or store hazardous materials or equipment. This could include common areas that you might share with other research groups. Pages 2-4 through 2-8 cover items to be included in the Laboratory Safety Plan.

Instructions for Updating a Laboratory Safety Plan

Each Principal Investigator is required to update the Laboratory Safety Plan at least annually or more often if changes occur. Changes may include addition or deletion of personnel, rooms, and research processes. Video tutorials for the laboratory safety plan can be found online.

Accessing the Online Plan

To create, view, or update an LSP, log in to the Laboratory Safety Plan web app with your ONYEN and password, and select the Principal Investigator from the drop-down list. Once the PI has been selected, you will see the Main Menu page with headings describing LSP states. Plans currently being edited will be in the “plans in process” state. Those that have been submitted to EHS for review and approval will be in the “plans pending approval” state. Approved plans will be under the “approved plans” heading. If you are a new PI or an existing PI that has moved buildings, there is a button to create a new plan at the bottom of the page.

Step 1: Building Selection

A drop down list of all University buildings is provided. Each building in which a PI has lab space needs its own Laboratory Safety Plan. If you do not see your building, please email chemsafety@ehs.unc.edu to request the addition of a new building. 

Step 2: Room Selection

Add any rooms where hazardous materials or equipment are used or stored by clicking the “Add Room” button near the bottom of the screen. Once all rooms are added, continue to Step 3.

Step 3: Hazard Selection

In the table, identify the room(s) in which hazards are present or hazardous operations occur.

  • Schedule B: Hazardous Chemicals and Equipment
  • Schedule C: Radioactive Materials
  • Schedule D: X-Ray Equipment
  • Schedule E: Laser Equipment
  • Schedule F: Biological Hazards
  • Schedule G: Recombinant or Synthetic Nucleic Acid Molecules
  • Schedule H: Transgenic Animals or Plants
  • Schedule I: Shipping
  • Schedule J: Clinical

Schedule A: Laboratory Project Information

Demographic Data

Provide pertinent contact information about the Principal Investigator, including their position title, department, email address, work phone number, and after-hours phone number. Also specify the person responsible for safety when the PI is absent, their work phone number, after-hours phone number, and email address.

The after-hours number can be a home phone number, cell phone number, or pager. First responders (EHS, UNC Police, and Chapel Hill Fire Department) will use it to contact the PI or the Safety Supervisor in the event of an after-hours or weekend emergency.

Employee Information and Training

The OSHA Laboratory Standard requires that supervisors advise employees of chemical hazards at the time of initial assignment and whenever new exposure situations occur. Keep a laboratory safety notebook as a reference for laboratory personnel. Indicate the location of this information in this table. The Laboratory Standard requires communicating the following information to employees:

  • Location and availability of the Chemical Hygiene Plan (Laboratory Safety Manual and Laboratory Safety Plan). These documents can be referenced online. Printed copies are not required except for the sections of the LSP which specify that they must be printed and posted.
  • Location and availability of known reference material (including safety data sheets) on the hazards, safe handling, storage, and disposal of hazardous chemicals.
  • Permissible Exposure Limits (PELs) for OSHA-regulated substances and recommended exposure limits for non-regulated substances.
  • Physical hazards and health hazards of chemicals in the workplace.
  • Signs and symptoms associated with exposures to hazardous chemicals used.
  • Documentation that each employee has received training from EHS on the OSHA Laboratory Standard. This information can be accessed online.
  • Documented annual review of the Laboratory Safety Plan for each person. This review is done through the online Laboratory Safety Plan application.

Laboratory Personnel

Each person working in the laboratory must complete an online Laboratory/Radiation/Clinical Worker Registration form (see Chapter 1 Appendix 1-A for instructions). The data entered in the Laboratory Worker Registration form automatically updates the Personnel section of the LSP. A green check indicates that a given employee works with a specific hazard (e.g. radiation, lasers, or materials of human origin). If the personnel information shown is incorrect, the worker registration form must be updated to reflect changes.

Floor Plans

Prepare a floor plan (See Appendix 2-A) for each laboratory room covered by the LSP, showing the location of hazardous materials (including wastes), benches, desks, laboratory hoods, fire extinguishers, spill control supplies, compressed gas cylinders, and any other items that could be of concern to emergency response personnel. Areas designated for food and beverage consumption must also be included on the diagram, if applicable. Floor plans may be uploaded as any supported file format, including JPEG, PNG, PDF, XLS, and DOCX files.

Schedule B: Hazardous Chemicals and Equipment

Hazard Identification

Each research group must prepare a summary of the types of hazardous materials stored in the laboratory to provide information to laboratory and emergency response personnel. Indicate the total quantity of each hazard/compatibility class (Chapter 4: Proper Storage of Chemicals in Laboratories).

An online Chemical Inventory System (CIS) is part of the Laboratory Safety Plan. Instructions for completing the CIS are included in Appendix 2-B and a video tutorial can be found online. Please consult the SDS or contact EHS if you have any questions about proper classification of chemicals before the online CIS is completed.

Laboratory Safety Rules and Procedures

The UNC Laboratory Safety Manual provides basic safety protocols. Each Principal Investigator must supplement the LSM with safe handling procedures, research protocols, and other safety procedures that are specific to their own research group. Items to address include:

  • Detailed procedures for handling toxic chemicals and “select carcinogens” (Chapter 7) that are used in the laboratory, including designation of the work area and entry restrictions
  • Identification of materials and procedures to be restricted to chemical fume hoods and biological safety cabinets
  • Designation of areas where eating or drinking is allowed or forbidden

Hazardous Waste Disposal

Describe the processes that generate hazardous waste in your lab, specify the type of waste generated, and estimate the amount of hazardous waste that will be generated on a weekly or monthly basis. Prepare procedures to ensure proper segregation, containment and storage of wastes. Give special attention to avoid mixing of incompatible wastes, and to ensure proper segregation to minimize potential reactions and incidents. Refer to Chapter 12: Laboratory Waste Management Plan and Hazardous Waste for detailed information on waste disposal.

Emergency Procedures

General emergency procedures are contained in Chapter 1 of this manual. Prepare specific procedures for each laboratory in the event of an emergency arising outside of the laboratory or within the laboratory. These procedures should include:

  • Actions to prevent harm to personnel, including communication plans, evacuation routes, and locations of first-aid equipment
  • Actions to prevent damage to equipment
  • Actions to prevent loss of experiments in progress
  • Actions to secure hazardous material in use at the time an emergency is sounded
  • Chemical spill response procedures, including location of spill kits

Personal Protective Equipment (PPE)

Identify the personal protective equipment required for laboratory procedures. Consult Chapter 5 of this manual for additional information and complete the PPE Table in the LSP form using the following procedure:

  • Conduct a walk-through survey of the laboratory to identify hazards for which eye, face, and hand PPE are required.
  • Identify specific work areas, materials or chemicals in the space provided under “Laboratory Operation”.
  • In the space under “Hazard” describe the potential hazards for which PPE is required.
  • Under “PPE Required” describe the specific PPE to be worn when performing that work activity, if greater than the minimum.

Schedules C & D: Radioactive Materials & X-Ray Equipment

To obtain authorization to procure and use radiation sources, a prospective Authorized User must submit Schedules C and/or D, as applicable. The Radiation Safety Officer will review the application and schedule an interview with the prospective user to evaluate the facilities available, the training and experience of the applicant and staff for the proposed use, and the details of the proposed research using radioactive materials or x-rays.

The procedures described in the application, as modified by the Radiation Safety Officer and/or the Radiation Safety Committee, become the conditions under which they authorize a researcher and his/her personnel to use radiation sources. The Radiation Safety Officer must review any subsequent change in procedure regarding the use, storage or disposal of sources prior to instituting the change. Please read the UNC Radiation Safety Manual for more information.

Schedule E: Laser Equipment

Provide information on the laser as requested on the form: location, laser type, manufacturer, beam characteristics, maximum output, frequency, aperture diameter, divergence, focal length, access controls, and emergency switch. List the names of the operators, and training requirements. You can revise the list of laser safety operating conditions in the UNC Laser Safety Manual to fit the specific conditions in the laboratory.

Schedule F: Biological Hazards Registration

Use the Biological Hazards Registration (Schedule F) form to provide initial and annual notification of biological hazards to EHS and all lab workers who access this space. For each biohazardous material, first indicate its category according to:

  1. microorganisms or animal source materials
  2. biological toxin
  3. human/primate source material (including well established cell lines)
  4. recombinant DNA

Then indicate which room(s) is (are) used for handling and/or storage.

Next, complete the series of prompts. Note that the prompts are specific for that category of material, examples include diseases/symptoms, medical surveillance, vaccination, handling practices and precautions, surface disinfection, and waste treatment. If you do not locate the organism or material that you need to register, you will need to call EHS at 919-966-5507 or email Biosafety to request the addition of that material.

Work at BSL-1 requires completion of the BSL-1 checklist. Work at or above BSL-2 requires completion of the BSL-2/3 checklist. Checklist items are derived from federal, state, and local regulations and requirements. Each room designated as being used for the presence or use of biological hazards must be evaluated against these criteria. Exclusion of any of the listed criteria requires a compelling and documented reason for having an exception to these requirements. Multiple rooms may be listed on a single form.

Schedule G: Recombinant DNA

The Schedule G is required for labs that perform research subject to the NIH Guidelines for Research Involving Recombinant or Synthetic Nucleic Acid Molecules (NIH Guidelines), Schedule Gs are reviewed by UNC's Institutional Biosafety Committee (IBC) on a monthly basis. The IBC typically convenes on the first Wednesday of each month (see the IBC webpage for the official meeting schedule), and Schedule G applications are due by the 15th of the month preceding the meeting. Since UNC as an institution receives federal funding, all researchers must abide by the NIH Guidelines regardless of their specific funding source(s). UNC also requires IBC review for all research activities that involve recombinant or synthetic nucleic acids (rsNA), and/or cells, organisms, or viruses that contain rsNA.  Additional information on the NIH Guidelines and rsNA can be found in Chapter 18 of the Biological Safety Manual.

Some considerations for filling out the Schedule G have been outlined below. Filling out the form thoroughly the first time around is the best way to ensure a swift and smooth review. To aide review, EHS's IBC Coordinator will perform a pre-meeting review of the applications and email recommendations for amendments that will increase the likelihood of the form being approved (instead of conditionally approved, tabled, or rejected). Contact ibc@office.unc.edu, biosafety@ehs.unc.edu, or the IBC Coordinator with additional questions regarding this form and its review process.

  1. When utilizing a Core Service, the PI commissioning the rsNA product/organism/experiment is responsible for ensuring the Schedule G is filed and reviewed in a timely manner. Core Services are expected to have a Schedule G filed for each type of rsNA procedure they perform for these facilities, the application can allude to commissioning investigators filing the paperwork necessary for specific manipulations/genes of interest (GOI).
  2. Section I of the Schedule G consists of classifying the proposed work according to the categories defined Section III of the NIH Guidelines. An overview of the most common research categories is provided on the rDNA webpage. Please note that if experiments fall under rsNA category III-D or III-E AND III-F, the work should be classified as III-F; alternatively, any experiments that fall under III-A, III-B, or III-C AND one of the other categories should be classified as the highest category (e.g., if experiments fulfill descriptions of both III-B and III-F, experiments should be categorized as III-B).
  3. Section II covers general project details, risk assessment, and in vitro experiments.
  4. A descriptive project title is required. The title should be clear enough for someone to know the general aim of the experiments.
  5. Under Section II Question 9, please clarify the function of your GOIs. If investigating/using similar genes (e.g., green fluorescent protein and red fluorescent protein), these can be grouped under the same description. If any GOIs have acronyms that were not clarified in the previous sections, write out their full names in the response.
  6. When copying a form to renew or amend it, please add something like, "- 2024 Amendment 1" or "- 2024 Renewal" to the title. A statement summarizing the changes, or noting "no changes as part of 2024 renewal," should also be added to the end of the aim (Section II Question 2).
  7. The risk assessment should be relevant to the material described and assess any occupational health considerations for the vector(s), GOIs, animals, cells, etc. For example, clarifying whether a GOI is known or suspected to be an oncogene in humans. Supplemental materials about risk assessments can be found on the rDNA webpage.
  8. Please include the strain(s) of organisms listed under Section II Question 13.
  9. Section III covers in vivo experiments, including the transfer of genetically modified cells into whole animals/plants. If a form is submitted that implies the project includes work in whole animals/plants but does NOT have a Section III (i.e., Section II Question 4 was marked "No"), the application will likely be held off the agenda or tabled until that section is completed.
  10. When selecting your containment level, please remember that UNC considers work involving human cell lines as (at least) BSL-2. If BSL-2 is marked in Section II, the PPE listed in Section III Question 4 should include all required ABSL-2 PPE (i.e., bonnet, booties, sleeves, gown, gloves, and surgical mask). If different containment levels will be used for in vitro vs in vivo manipulations, please include some type of clarification for this.
  11. In order for your Schedule G to be considered for approval, the entire form must be filled out completely and signed by the PI. Approval is valid for five years or the length of the grant funding period if less than five years.

Schedule H: Use of Transgenic Animals or Plants

A Schedule H is required to be filled out when you are acquiring transgenic animals or plants from researchers (including other UNC researchers) or from outside vendors. If your IACUC protocol states that it utilizes transgenic animals, you will be required to provide the IACUC with an approved Schedule H. Some considerations for filling out a Schedule H have been outlined below. 

  1. Fill out the entire form, being as detailed as possible. 
  2. Fully describe the genetic alterations and/or foreign genes expressed.
  3. A descriptive project title is required for approval.
  4. In instances where the PI is not the one filling out a Schedule H, the PI must approve the application in the system before EHS can grant approval. 
  5. Most Schedule H applications will fall under BSL-1 level containment. If your animal is expressing human genes or is being transfected by replication-competent vectors (including Adenovirus, Retrovirus, or wild-type Cowpox), this application will fall under BSL-2 level containment. 

Schedule I: Shipping

Complete the Schedule I form if you will be shipping any equipment, chemicals, or biological materials from your lab.  When filling out your Schedule I, you will be prompted to input the following information pertaining to your laboratory’s shipments:

  1. Building location where the shipments will be packaged or received
  2. Room number(s) of the building where the shipments will be packaged or received
  3. The designated laboratory shipping coordinator(s) responsible for packaging or receiving materials
  4. Indication of dry ice usage
  5. A detailed description of the items expected to be shipped please be sure to include as much information as possible in this section as it can result in a denial of you Schedule I.
  6. Provide a list of all domestic and international destinations relevant to your shipments

 Additional guidance on shipping and compliance can be found on the UNC Transporting Research Materials webpage or reached by emailing UNC EHS Shipping.

Schedule J: Clinical

The Schedule J is intended to serve as a truncated form of the LSP for clinical researchers with minimal hazards. Activities that would warrant a Schedule J include:

  1. Simple specimen collection (e.g., urine, feces, saliva) or phlebotomy without additional processing/testing on-site
  2. Clinical specimen storage
  3. Data collection only

If the questions on the Schedule J do not cover all aspects of your research, please reach out to EHS to discuss the appropriate documentation; if work involves hazardous chemicals/equipment, radiation, etiological agents, shipping, etc., the relevant sections of the LSP will likely be required.

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