(A)
Purpose
University investigators often use
hazardous chemicals or agents as part of their laboratory research. Through
requirements established in the Chemical Hygiene Plan. Biosafety Manual.
Radiation Safety Manual, and regulations instituted by federal and state
agencies, investigators must properly handle and control these chemicals and
agents to protect persons and the environment. This policy extends the
requirement for investigators to maintain control of these materials and
potentially contaminated spaces through the process of closing out their
laboratory. A principle investigator who permanently vacates laboratory space
as part of relocating to another laboratory at the university, transferring to
another university, retiring, or suspending laboratory operations for any other
reason must ensure that all environmental and occupational health and safety
regulations are met to assure a safe work area for future users.
(B)
Applicability
This policy applies to the
closeout/decommissioning of any university laboratory that had operations
dealing with hazardous materials. For the purpose of this policy, hazardous
material includes chemicals, radioactive materials, and biological, infectious,
or zoonotic agents or toxins. This policy also applies to hazardous materials
belonging to the vacating principal investigator, but stored in a shared use or
storage space (e.g.. cold room, freezer, or stock room).
(C)
Responsibilities
(1)
Principal investigator
The principal investigator (PI) is a
faculty or staff member serving as the responsible individual of the
laboratory. The PI retains responsibility for proper management of hazardous
materials and contaminated equipment or laboratory surfaces. At least one month
before vacating the laboratory space or as soon as the decision is made, the PI
will inform the director of environmental health and safety (EHS) of the
planned move. The PI will meet with the director of EHS or his/her
representative to discuss the close out process. If necessary, the department
chair may be involved in the discussion. The director of EHS will provide the
PI a copy of the "Laboratory Clearance Checklist" which will be used to
complete the Exit Clearance process (see section
paragraph (E) of
this rule).
(2)
Department chair or director
The chair or director is accountable
for laboratory space assigned to the department. The chair or director must
ensure the director of EHS is timely informed of planned laboratory closeouts.
In the event services beyond those routinely performed by EHS are required,
such that an outside contractor is needed, the responsible department will be
charged for purchased services. Any regulatory action or fines resulting from
improper management of hazardous materials will be charged to the responsible
department.
(3)
Environmental health and safety (EHS)
EHS will work with the PI to develop a
management plan for the proper management and disposal of hazardous material
and with developing procedures for the required decontamination of equipment or
laboratory surfaces. EHS is responsible for the costs associated with the
disposal of hazardous materials that have been managed as required under
applicable procedures. EHS staff will perform the final inspection of a vacated
laboratory, along with the PI as described in section
paragraph (E) of
this rule, and will release the laboratory for fixture use once all
requirements have been met.
(4)
Laboratory animal
resources (LAR)
The director of LAR is responsible for
the management of all controlled substances regulated by the federal drug
enforcement agency (DEA) and for the incineration of all animal waste not
meeting the Ohio environmental protection agency's (OEPA) definition of
infectious waste.
(D)
Procedures
Principal investigators shall follow
the procedures in this section to manage hazardous material when exiting a
laboratory. Any equipment or laboratory surface that is contaminated with any
hazardous material must be decontaminated as described in this section
paragraph.
(1)
Chemicals. References: rule 3352-7-20 of the
Administrative Code 3352-7-20
.
(a)
Any chemical distributed to you as a DEA controlled
substance must be returned to the director, laboratory animal resources, prior
to exiting the laboratory.
(b)
Chemicals can be
transferred to other laboratories within the department, or other university
departments, with the acknowledgement of EHS and updating the laboratory
chemical inventory of the accepting location. Contact EHS prior to transference
of any chemicals.
(c)
Hazardous chemicals transported off campus must comply
with applicable U.S. department of transportation (DOT) regulations by
following EHS's procedures on transportation of hazardous materials. These
procedures can be accessed on the EHS website at http://www.wright.edu/admin/ehs.
(d)
Chemicals you
wish to have managed by EHS must be properly containerized and labeled. Proper
labeling requires the chemical name of each chemical to be listed on the
container. If a container has a mixture of chemicals, each chemical must be
listed with its relative percentage. Chemical formulas, abbreviations, or trade
names are not acceptable. For any commercial chemical product that is not
labeled with its chemical name, a "Material Safety Data Sheet" must be
requested from the company and supplied to EHS with the chemical. Contact EHS
to arrange for chemical pick up.
(e)
If the
investigator is leaving the university, return the WSU chemical hygiene plan to
EHS.
(2)
Radioactive material. Reference: "University Radiation
Safety Manual" (RSM) Authorized users must:
(a)
Inform the
radiation safety officer (RSO) at least two weeks prior to the laboratory
closeout.
(b)
Terminate their radioactive materials protocols
(section of 2.6.4 of the RSM).
(c)
Ensure laboratory
facilities and equipment are free of contamination (sections 2.18 and 2.19 of
the RSM).
(d)
Ensure all radioactive materials, radioactive waste,
and potentially contaminated equipment or surfaces are properly labeled
(sections 2.17 and 2.24 of the RSM).
(e)
Returned all
remaining radioactive materials and dispose of radioactive waste to the
radiation safety office (sections 2.24 of the RSMV
(f)
If the authorized
user is leaving the university, return the "Radiation Safety Manual," personnel
dosimeters, survey meters, radiation protection equipment, and shielding
devices to the radiation safety office.
(g)
Inform the RSO if
any radioactive material will be transferred to another authorized user.
another location on campus, or to another licensed institution (section 2.14.3
and 2.15 of the RSM).
(h)
Schedule a final laboratory radiation survey (and
bioassay. if appropriate) with the radiation safety office.
(3)
Biological and infectious material
References: Wright state university's
Institutional Biosafety Manual; Wright state university's Infectious Waste
Management Guide; Title 42 Code of Federal Regulations Part 73. If you are
leaving the university and were issued an Institutional Biosafety Manual,
return it to the university institutional biosafety officer.
(a)
Select
agents:
(i)
Certain biological material and toxins considered select
agents (se 42 CRF 73.4 and 73.5) cannot be transferred to other university
personnel or transported off campus without prior approval from EHS, the
institutional biological safety officer, the department of health and human
services, and/or the United States department of agriculture.
(ii)
The disposal of
select agents, if meeting the OEPA definition of infectious waste (see
paragraph (D)(3)(b) of this rule below
, shall be managed as
described in the section for infectious waste. Select agents not meeting the
definition of infectious waste must be handled on a case by case basis. Contact
the institutional biological safety officer for assistance.
(b)
Infectious waste:
(i)
All waste
material meeting the OEPA definition of infectious waste must be collected by
EHS except in cases when liquid infectious waste cultures can be treated with
bleach and disposed down the drain. OEPA's definition of infectious waste can
be found in the "Infectious Waste Management Guide;" appendix D in the WSU
"Institutional Biosafety Manual,"or on the EHS website at http://www.wright.edu/admin/ehs
. In all cases. EHS must be notified. Prior to EHS picking
up any infectious waste, or when treating liquid infectious waste cultures, all
waste must be managed as described in the "Infectious Waste Management
Guide".
(ii)
In no cases shall material meeting the OEPA's
definition of infectious waste be autoclaved and disposed as regular trash or
sent to laboratory animal resources for incineration.
(iii)
Contact
environmental health and safety to obtain any needed infectious waste boxes or
to schedule a pick up of infectious waste.
(c)
Animal and human
tissue:
(i)
If
tissue is held in a liquid preservative, tissue and liquid must be separated.
(ii)
Liquid preservative shall be managed as described in the
chemicals paragraph section
of this rule policy
.
(iii)
Tissue meeting
the OEPA definition of infectious waste must be collected by EHS. Prior to EHS
picking up any infectious waste it must be managed as described in the
"Infectious Waste Management Guide" of the WSU "Institutional Biosafety Manual"
(appendix D). OEPA's definition of infectious waste can be found in the
management guide which can be viewed on EHS's website:
http://www.wright.edu/admin/ehs/.
(iv)
Tissue not
meeting the definition of infectious waste shall be collected and sent to
laboratory Animal Resources for incineration.
(d)
Toxins:
(i)
Toxins must be
handled on a case by case basis. Contact EHS for instructions.
(ii)
Toxins
considered a select agent will be managed for disposal, transfer, or transport
according to 42 CFR 72 and 73 .
(4)
Laboratory
equipment and surfaces
a)
Any laboratory equipment or laboratory surface that is
contaminated with a hazardous material must be decontaminated prior to exiting
the lab or distribution of the equipment. Proper decontamination requires the
wipe down of all contaminated surfaces with a solvent or cleaning agent capable
of removing the contaminant. Any equipment that contains a hazardous material
integral to the operation of the equipment (i.e.. oil, mercury, refrigerant,
asbestos...) must have the hazardous material removed prior to disposal. The
exception to this is if Wright state university's excess and surplus management
department (ESPM) plans to sell the equipment as useable.
b)
Any laboratory
equipment that is contaminated with, or contains, radioactive material must go
through a specific clearance process initiated by the radiation safety office.
Refer to the radioactive material section of this policy for
guidance.
c)
ESPM must manage all equipment for disposal or resale.
Refer to Wright State University's Wright Way Policy Manual Policy 5403 for the
requirements of ESPM. Specifically, policy 5403.6(e) stipulates the
requirements for handling equipment that contains or is contaminated with a
hazardous material. These requirements must be satisfied.
(E)
Laboratory exit clearance
1)
After all
hazardous material has been managed as described in this policy; contact EHS,
(937) 775-2215, to set up a laboratory clearance meeting. The meeting shall be
held in the laboratory and attended by the principal investigator and an EHS
representative(s). Either the principal investigator or EHS may request that
the department chair or director attend the meeting.
2)
The EHS
representative(s), with assistance from the principal investigator, will
complete the EHS "Laboratory Clearance Checklist." The checklist will be signed
by the principal investigator and the chair or director of the department or
administrative unit after which the lab will be considered safe for reuse by
another investigator. he completed and signed Clearance Checklist will be kept
on file in EHS permanently.
Replaces:
3352.03
