Annual Lab Review Process

Research laboratories are reviewed by EHS annually.  The review procedure for laboratories is as follows:

  1. A member of the EHS Safety Advisor Team will e-mail the principal investigator (and designated lab contact, if applicable) and 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 primary audit.
  1. As soon as possible, the delegate or PI should update the TNA and send it back to their Advisor.
  • If returned before the audit, the Advisor will query for missing worker training. This enables the PI/delegate to know exactly what training courses are missing for each individual. It also speeds up the lab review meeting. 
  1. The PI/delegate should prepare the needed paperwork prior to the audit. The most commonly needed paperwork is listed here: Lab Safety Audit Documentation.
  2. The PI/delegate should read the Lab Review Checklist to become familiar with the items that will be covered during the review. The current Checklist is available here: EHS Lab Review Topics List.
  3. 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.
  • At the end of the meeting, the Advisor will review any necessary corrective actions with the PI/delegate. 
  1. 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.
  1. 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.
  2. 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. 
  1. Thirty days later the Advisor will return to the lab 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.
  1. 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, copying the EHS Director, HSC, and DEO. This letter will detail any outstanding issues and the appropriate corrective action.
  1. At the end of each year, EHS will compile a report that lists the safety/regulatory concerns that were not addressed within the 30-day period and the associated lab. This report will be sent by the EHS Director to the DEOs and the Office of the Vice President for Research.

If you have questions about how to complete any of the requirements, you may contact your Safety Advisor. Alternately, you may contact the co-leads of the Safety Advisor Team, Joe Hawk (384.4541) or Rachelle Justice (353.4692).