Annual Lab Review Process

Research laboratories are reviewed by EHS annually.  The review procedure for laboratories is described below.

Scheduling the Review

A member of the EHS Safety Advisor Team will e-mail the principal investigator (and designated lab contact, if applicable) to schedule a time for the lab review. This typically happens two to three weeks before the intended visit.

  • The e-mail will contain instructions for how to prepare for the review, the Lab Review Checklist, and the Training Needs Assessment (TNA). The PI may delegate a staff member to meet with the Safety Advisor in their stead.  This person must be familiar with the lab’s research and capable of answering the Advisor’s questions. 
    1. DoD and Army grant recipients must meet the Safety Advisor briefly in-person but the delegate can conduct the remainder of the lab visit.
  • The Advisor will also schedule a 30-day follow-up visit at this time in case any corrective actions are needed following the initial review.

Preparing for the Review

The PI/delegate should prepare the needed paperwork prior to the review and become familiar with the Lab Review Checklist. The most commonly needed paperwork is listed below.
 
If the PI or lab representative have questions about how to complete any of the requirements, they may contact the lab’s Advisor for assistance prior to the visit.

  1. Read the Lab Review Topics List- Please familiarize yourself with this document so you will be able to answer these questions.
  2. Chemical Hygiene Plan (CHP) Annual Review- The CHP covers basic lab safety practices. 
    All staff (including students working in the lab) must review the CHP each year. After doing so, each person must provide their signature certifying they have reviewed the CHP. 
  3. PPE Hazard Assessment Tool (PPE HAT) - The PPE HAT covers PPE recommendations. Review the PPE HAT and make any necessary updates. All staff must review the PPE HAT once per year as well. After doing so, each person must provide their signature certifying they have reviewed the PPE HAT. The hazard assessment tool template, includes step-by-step instructions and a signature page. 
  4. Safety Training for ALL Staff- Needed for EACH staff member. 
  • Proof of ICON Training- For a list of required training courses, see the “Required Training” document below.
  1. If a complete “Training Needs Assessment” document is returned to the Advisor before the review, the Advisor will prepare a report listing any staff missing training. When this is done in advance, no “My Training” records will be needed at your lab review. 
  • Site Specific Checklists (SSC), as applicable -
    • Lab Chemical Safety - These forms must be completed by everyone, once at the beginning of employment, and redone only if the lab moves. The Advisor will collect these dates and record them for future years.
    • Shipping Biohazardous Waste Tubs - These forms must be completed by everyone every three years. The Advisor will collect these dates and record them for future years.
    • Additional Site Specific Checklists (as applicable) - Additional forms may include Bloodborne Pathogens, Shipping Infectious Substances OR Shipping with Dry Ice, Electrical Panel Breaker Resetting. Again, the Advisor will collect these dates and record them for future years.
  1. Documentation of Respiratory Program - If applicable to the lab, the written program for respirator use must be completed/updated.
  2. Biological Agent Inventory – The Advisor will send the current Biological Agent Inventory, as known by EHS. Review and update the inventory as necessary. The inventory should not list genetically altered agents separately, unless the genetic changes are expected to increase the transmissibility or pathogenicity of the altered agent above those of the parental strain. 
Agent Classification Replication Defective? Recombinant? Risk Group Inventory Status Inventory Date Comments
E coli K12 Bacteria No Yes 1 In Use 9/10/2015  
E. Coli Non K12 Bacteria No Yes 1 In Use 9/10/2015  

During the Review

At the scheduled time, the Advisor will meet with the appointed lab member. The Advisor will review the required paperwork, go through the checklist items, and conduct a walk-through of the lab space.

  • Photographs may be taken of any deficiencies, other than paperwork.  Repeat photos will be taken, as necessary.

At the end of the meeting, the Advisor will review any necessary corrective actions with the PI/delegate. 

Post-Review Follow-up

Some safety issues must be addressed within 24 hours. The PI/delegate must e-mail their Advisor with proof (photograph, scan, invoice, etc.) of how they resolved the problem by the end of the following business day.

  • If the lab does not respond within 24 hours, an e-mail reminder will be sent to the PI, copying the delegate, if applicable, the department’s Health and Safety Coordinator (HSC), the Departmental Executive Officer (DEO), and the EHS Director.

A report of the laboratory review will be sent to the PI, and copied to the delegate, within one week. The report will detail any safety/regulatory concerns and will provide appropriate corrective actions.

  • Any photographs taken during the review will be available to the PI and delegate, if applicable.
  • The report will identify any repeat concerns that were not resolved in prior years.

If no concerns were identified or remain following the review, no further action is needed.  If corrective actions are required, the lab must address all noted concerns within one month from the initial inspection. The PI/delegate can send proof of completion to their Advisor at any time during those thirty days. 

  • Options for proof include scans (e.g. completed CHP signature page), photographs (e.g. eyewash that has been unblocked), invoice/receipt of a needed purchase, copy of an e-mail (e.g. cc the Advisor on an e-mail to the Waste group for peroxide testing), etc. 

Re-inspection, if needed

Thirty days later the Advisor will return to the lab, if necessary, to verify the concerns were addressed.

  • If all concerns were resolved before the follow-up meeting (by sending proof of completion to the Advisor), the follow-up meeting can be canceled.

After the follow-up meeting, the Advisor will send a final report to the PI and copy the delegate, if applicable.

  • If all concerns were addressed, a Satisfactory letter will be sent and no further actions are needed.
  • If all concerns were not addressed, a Deficiency letter will be sent within one business day, copying the EHS Director, Chemical Hygiene Officer, Biosafety Officer (if applicable), HSC, and DEO. This letter will detail any outstanding issues and the appropriate corrective action.

Annual Reporting

At the end of each calendar year, EHS will compile a report that lists the safety/regulatory concern(s) that were noted during the safety review; the report will detail each PI and associated concerns.  The report will also note whether the item was corrected or remained outstanding after the 30-day period. This report will be sent by the EHS Director to the the Health & Safety Coordinators, DEOs, Risk Management, and the Office of the Vice President for Research. 

Lab Safety Rounds

As part of the overall safety review procedure, EHS will also visit labs during Lab Safety Rounds.  The Lab Safety Round is an unannounced walkthrough of the research labs; click here to review the full procedure. 

Questions about this topic can be directed here

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