Preparing for the Annual Lab Review

Research laboratories are reviewed by EHS annually.  This document provides guidance for how to prepare for this annual review.  The principal investigator/lab supervisor will be contacted by a member of the EHS Safety Advisor Team by e-mail to schedule a time for the lab review.  The e-mail will contain concise instructions and will include a copy of the current Lab Review checklist that needs to be completed by the lab.  It is advisable to keep this e-mail until the annual lab review process is complete.  In most cases, the PI/supervisor may elect to have a designated staff member of the respective lab meet with the EHS Safety Advisor for the lab review.  Occasionally the EHS Safety Advisor may need to meet briefly with the PI in person but the designated staff member can manage the remainder of the lab visit.
Below are some steps to follow to prepare for the lab review.  Please have all documentation completed and available at the scheduled lab review time.  If you have questions about how to complete any of the requirements, you may contact your Safety Advisor for assistance prior to the lab visit.

The Following Items Must Be Completed Before the Lab Review:

1. The Lab Review Checklist – Complete all questions

Bio/Chemical Lab Self Audit

2. Chemical Hygiene Plan (CHP) Annual Review- the CHP covers basic lab safety practices and documents how UI complies with the OSHA/IOSH Lab Standard. 

All staff (including students working in the lab) must review the CHP once per year either as a group or individually. After doing so, each person must provide their signature and date certifying they have reviewed the CHP. The review documentation form is available through the following link:

CHP Annual Review Documentation Form

3. Chemical Inventory Review/Update

Know the date of the last update of the EHS Assistant (EHSA) Chemical Inventory. Ensure that it has been updated in the past 60 days.  The date will be listed under “Last Chemical Review Date.”

EHS Assistant Login Page

4. PPE Hazard Assessment Tool (PPE HAT)

Review- the PPE HAT covers personal protective equipment needed for various tasks.   This tool is used to comply with the OSHA/IOSH PPE regulations in labs.

The PI or the PI’s designee reviews the PPE HAT and makes any necessary updates.  Following this review/update, a current review date must be supplied in the Hazard Assessment Certification section on page 7 (next to previous review date).  See example of page 7 below.

All staff must review the PPE HAT either as a group or individually once per year as part of their training. After doing so, each person must supply their signature certifying they have reviewed the PPE HAT.  The trainer (PI or PI’s designee) signs and dates (or adds a new date only next to previous date) at the bottom of the page where it says “(Signature of Trainer)”.  See example of the page below.

The hazard assessment tool template, including step-by-step instructions, is available on by clicking on the following link: PPE: Research Laboratory Hazard Assessment Tool.

5. Documentation of Respiratory Program

If anyone in your lab wears a respirator/dust mask, a documented hazard assessment needs to be completed and maintained on file in the lab.   If the lab does not have a hazard assessment on file, an evaluation request should be filled out.  The form to request a respirator/dust mask evaluation is available on the following link: Lab Request for Respirator Use Evaluation.
Please prepare the request prior to the lab review meeting if an evaluation is needed.  An EHS representative will complete the evaluation upon request and provide documentation for you to keep in the lab safety folder.  See an example of the request form below.

6. Biological Agent Inventory

You will be sent a list of biological agents listed in current EHS records for your lab.  Review the list prior to the lab review and update the information as necessary.  Please provide a copy of the updated information at the lab visit.
The inventory should include all agents currently in use as well as those in storage. The inventory should not list genetically altered agents separately, such as those generated by recombinant DNA methods or chemical mutagenesis, unless the genetic changes are known to or would be expected to increase the transmissibility or pathogenicity of the altered agent above those of the parental agent. If you have any questions call EHS at 335-8501. 

Bacteria Viruses Fungi Parasites Toxins

Any items highlighted in red are the agents we have listed as being used for recombinant work; please confirm that our list is accurate and highlight any new agents which are used for recombinant work. If there are any items listed in purple, we need more specific information about the agent (such as genus/species or viral backbone).  

7. Bloodborne Pathogen Information

On the Lab Review Checklist, complete the following, if applicable: 

  • Enter name of your department’s Exposure Control Officer (ECO)
  • Enter Location of Exposure Control Plan (ECP)
  • Enter Date of last update of ECP by the department ECO
  • Ensure that all lab staff have access to and are familiar with the ECP
  • Ensure that all lab staff have been offered the Hepatitis B vaccination.
    • If necessary, have outstanding staff complete the online Hepatitis B vaccination survey offered by UEHC on ReadySet. The survey instructions are available on the EHS website. 

8. Safety Training Records for ALL Staff- There are three (3) items needed for EACH staff member. For a list of required training courses, see the attached document “Required Training” in the e-mail sent to you for the lab review visit.

I. Employees: HR “My Training” Page- Each lab member must log-on to the HR Self-Service Site and print their “My Training” page on the UI HR Self Service Web Site
Unpaid lab workers: Icon safety courses – Each unpaid lab member must log-on to ICON and print the first page of the applicable training courses. ICON Login Non-paid Student/Guest

II. Site Specific Checklist for the Lab Chemical Safety Training- See document attached to your lab visit e-mail “LabChemSS”. These checklists only need be completed once if no additional lab chemical hazards are introduced to the lab. If you have these completed from previous years, simply have them available; they do not need to be re-done.

III. Site Specific Checklist for the Bloodborne Pathogens Training (if applicable) - See document attached to your lab visit e-mail “BloodbornePathSS”. Similar to Lab Chemical Site-Specific, these only need be completed once.

 Use the information from the above training documentation to complete the “Worksheet to Determine Training Status”; this is the last page of the 2012 Lab Review Checklist.  See example page below.

The commonly required training courses are listed in the “Worksheet to Determine Training Status”.  The following training courses are required more frequently than once.

BBP Refresher – Annual
Radiation Refresher - Annual
Hazardous Waste (for at least 1 person per lab) – Annual
Shipping – Every 2 years
Formaldehyde Safety – Annual only if lab formaldehyde work tasks result in formaldehyde exposure greater than 0.1 parts per million