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. Appendix 2-A: 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 you with safety information specific to the laboratory in which you work. Annual communication of LSP contents to laboratory personnel by the Principal Investigator provides the minimum specific training required by the 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, rather than printing out a copy and mailing it to EHS.

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 the items that are 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 include but are not limited to addition/deletion of personnel, rooms, and research processes.

Accessing the Online Plan

To create, view, or update an LSP, login to the online Laboratory Safety Plan with your Onyen and password. Select the Principal Investigator from the drop-down list by scrolling or typing the PI’s last name. Once the PI has been selected, you will see the Plans “in process…”, “pending approval…”, and “Approved”, and a link to “Create a New Plan”.

The link to “Create a New Plan” is selected by new Principal Investigators and any PI that has previously submitted a paper copy of a Laboratory Safety Plan.

Step 1: Building Selection

A dropdown menu of all University buildings is provided. Remember, each building in which a PI has lab space will have its own Laboratory Safety Plan.

Step 2: Room Selection

A dropdown menu of rooms in that building is provided. Select rooms from this list or type in the space provided. Once all rooms are added, continue to Step 3.

Step 3: Hazard Selection

In the table, identify under the room number which schedules or type of operation occur in that room.

• 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 A: Laboratory Project Information

Demographic Data

Provide pertinent demographic information about the Principal Investigator, including position title, department, email address, after hours phone number, person responsible for safety in absence of PI, lab 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 Public Safety, and Chapel Hill Fire Department) will use it to contact the PI or the Safety Supervisor in the event of an emergency after hours or on weekends.

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 that are 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.

Laboratory Personnel

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

Floor Plans

Prepare a floor plan 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.

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 online Laboratory Safety Plan. This system includes several of the most common chemicals used in the laboratory in a drop-down menu format. Instructions for completing the CIS are included in Appendix 2-A. 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 his or her research group. Items you are 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 that are to be restricted to laboratory hoods and biological safety cabinets
• Designation of areas where eating or drinking is allowed, if any (also indicate areas on the floor plan)

Hazardous Waste Disposal

Describe the processes that generate hazardous waste in your lab, the waste streams 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 disposal costs. Refer to Chapter 12: Management of Laboratory Wastes 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 as well as those that might arise within the laboratory. These procedures should include:

• 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

Personal Protective Equipment (PPE)

Identify the personal protective equipment required for laboratory procedures. Consult Chapter 5 of this manual for additional information and complete Table 4 in the LSP form using the following procedure:

• Conduct a walk-through survey of 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.

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 attached list of laser safety operating conditions 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 reagent, first indicate its category according to:

1. microorganism
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 to request the addition of that material.

Work at or above BSL-2 requires completion of the BSL-2 checklist. BSL-2 checklist items are derived from federal, state, and local regulations and requirements. Each room designated at BSL-2 must be evaluated against these criteria. Multiple rooms may be listed on a single form.

Schedule G: Recombinant DNA

• Forms are due to Environment Health and Safety (CB #1650) by the 15th of the month.
• The Schedule G is required when you are making rDNA. The top portion of the document is for administrative information including Principal Investigator name, PID, CB number, etc.
• As a part of Schedule G you are required to classify your research using the link to the Classification Summary Page for NIH Guidelines.
• A project title is required. You will need to identify the proteins being produced under #2.
• If you click “yes” under #3, you must fill out Section III Entitled “Gene Transfer Experiments”.
• Number 4 asks you to specify your containment level. Please remember if your recipient organism is human cells lines then you must classify your project as BSL2. If the vector you are using (i.e. lentiviral vector) is a BSL2 vector then you will classify your containment level as BSL2.
• If you are working at BSL3 then your containment level is going to be BSL3.
• Please do not forget to describe the experiment fully under #8.
• When using vectors under Section III please remember to attach a map of the vector.
• In order for your Schedule G to be considered for approval, the entire form must be filled out and signed. 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

• Forms are due to Environment Health and Safety (CB #1650) by the 15th of the month.
• Schedule H is required to be filled out when you are acquiring transgenic mice from other researchers (including UNC) or outside companies such as Jackson labs. If your IACUC protocol lists transgenic mice, you will be required to provide the IACUC with an approved Schedule H. The Institutional Biosafety Committee must approve the Schedule H and send it to the IACUC.
• The top portion of the document is for administrative information including Principal Investigator name, PID, CB number, etc.
• A project title is required. Under #1 list where the animal was produced.
• It is important to fill out the entire form.
• Under containment level most Schedule H applications fall under BSL1 containment. If your animal is expressing human genes or is being transfected by replication competent vectors such as Adenovirus, Retroviruses or wild type Cowpox, then your animals would be classified as BSL2.

Schedule I: Shipping

Complete the Schedule I form if you will be shipping any equipment, chemicals, or biological materials from your lab. List your lab’s shipping coordinator, any others who will prepare packages, the items you will send, and the destinations where you will ship.

Appendix 2-A: Online Chemical Inventory Instructions

For first time users only, if you maintain your inventory in some other format, please contact EHS so we may assist you in importing your inventory data in to our system.

For returning users, log onto the EHS chemical inventory site with your Onyen and password. Select an option in the left hand menu to get started.

Chemical Inventory

Add Inventory

1. Enter the Chemical Abstracts Service (CAS) number or chemical name into the “Chemical Search” box. Your chemical will show up in the drop down box. EHS has a database of over 60,000 chemicals, however if you do not find a match try an alternate name or a different spelling. Some chemicals in the database might not be listed under the name that you are more familiar with. Use the “User-Defined Name” to enter that information.
2. Enter the “Quantity on Hand” and the unit of measure. You can also enter the concentration/molarity. Enter the “Maximum Quantity on Hand” if you would like to provide that information as well.
3. Enter the chemical state (solid, liquid, or gas).
4. Select the check box to indicate if you would like to “Share this Chemical?” with others. This option is to indicate that you would like to make some, or all, of this chemical available to someone else if they may need it. This reduces the cost of disposing hazardous materials and saves other researchers the expense of purchasing chemicals. This information is kept on a secure server.
5. Select the “Building” and “Room” where the chemical is located.
6. Enter the location within the room (i.e. cabinet, refrigerator, shelf, etc.). You can also optionally enter where in the location (e.g. top shelf, left side, or which refrigerator, freezer, etc.) the chemical is located.
7. Add any “Notes” that you or EHS may find helpful when reviewing your inventory.
8. Select compatibility groups (Chapter 4) associated with your chemical.
9. Click the “Add Inventory Item” Button, and repeat for each chemical that you would like to add.

Update/Remove Inventory

1. Select the “Sort by” type and location you would like to view and click the [Search] button.
2. Enter the new quantity and click the [Update] button to the right.
3. If you no longer have the item, click the [Remove] button next to that inventory item.
4. Click the chemical name if you would like to update any other information for that chemical.

Search Your Inventory

1. Select the “Search by” type.
2. Enter the information for the chemical you would like to find in your inventory. You can enter a partial term to find many chemicals. For example, if you type “a”, your search will return all the chemicals in your inventory that begin with the letter “a”.
3. Click the [Search] button.
4. Click the chemical name link for the one you would like to view/update.

Add New Chemical

If you would like to add a new chemical to the EHS database, please fill out the form and submit to EHS.

Reports

Inventory by Location

Create an inventory report where the results are listed by the location of the chemical. You can select all locations or just a specific one. Reports can be sorted by chemical name, CAS no., or date of inventory update.

Inventory by Building

Create an inventory report where the results are listed by the building(s) on your Laboratory Safety Plan. You can only select one building at a time, and then you can select all storage locations or just a specific one. Reports can be sorted by chemical name, CAS no., or date of inventory update.

Inventory with Compatibility Groups

Create a report of chemicals in your inventory and their associated compatibility group. Use this report to verify that incompatible chemicals are not being stored together and that storage areas are clearly labeled.

Back to Chapter One

Proceed to Chapter Three