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Operating Policy and Procedure

Operating Policy and Procedure

HSC OP: 75.09, General Laboratory Use Policy

PURPOSE: The purpose of this Health Sciences Center Operating Policy and Procedure (HSC OP) is to comply with guidelines and/or regulations applicable to laboratory procedures and to provide for the safety of personnel working in or with access to laboratories. It is intended to establish guidelines to:

1. Identify space within the institution in which laboratory work (such as research, diagnostics, teaching) takes place;

2. Identify space in which laboratory work involving hazardous materials (such as radioisotopes, chemicals, biological material, recombinant or synthetic nucleic acid molecules), lasers, radiation producing equipment or animals takes place;

3. Reduce institutional risk through implementation of chemical/biological inventory controls, and accountability programs, including procurement review.

4. Verify that special approvals for any type of activity requiring such approval have been obtained;

5. Verify that the space is suitable for the designated activities, and that all special safety requirements for that type of activity are being met;

6. Designate a qualified individual and alternate to be responsible for the activities conducted and the personnel working in that space;

7. Identify personnel working in or having access to that space with access limitations provided as necessary; and

8. Provide adequate training of personnel for the designated type of activity and to meet applicable rules, regulations, and good practice standards.

REVIEW: This HSC OP will be reviewed on May 15 of each even-numbered year (ENY) by the Director for Safety Services, with recommendations for revision forwarded to the Vice President for Facilities and Safety Services and the Senior Vice President for Research and Innovation by August 31.

POLICY/PROCEDURES:

Definitions.

a. Amendment: Document indicating changes in activities, laboratory location or space, or laboratory workers.

b. Institutional Animal Care and Use Committee (IACUC): The institutional committee responsible for review, approval, training, risk analysis and oversight related to care and use of animals for teaching and research.

c. Institutional Biosafety Committee (IBC): The institutional committee responsible for review, approval, training, risk analysis and oversight related to all use of hazardous biological materials and/or hazardous chemical materials, and recombinant/synthetic nucleic acids on all 香蕉直播 campuses.

d. Institutional Embryonic Stem Cell Research Oversight Committee (ESCRO): the institutional committee providing oversight of all issues related to derivation and use of human stem cell lines.

e. Institutional Radiation Safety Committee (RSC): The institutional committee responsible for approval, training, risk analysis and oversight related to all use of radioactive materials.

f. Institutional Review Board (IRB) reviews research involving human subjects on all 香蕉直播 campuses.

g. Laboratory: Any space within 香蕉直播 facilities in which chemicals, biological agents or animals are used for research and educational activities, excluding space occupied by the Laboratory Animal Resource Center (LARC).

h. Laboratory Worker: Any person working in a laboratory, regardless of the person's employment status. This includes faculty, staff, students, volunteers and visiting associates.

i. Principal Investigator (PI): That person who has been designated as being responsible for the laboratory space, including supervision of research and staff. (See HSC OP 75.10, Section 1.l.) Such designation shall be made in writing by the Department Chair/Unit Supervisor. An alternate individual shall be designated as responsible when the Principal Investigator is unavailable or absent.

j. Protocol: Description of the procedures involving animals, biohazardous materials, recombinant or synthetic nucleic acid molecules, chemical materials, or radioactive material, the laboratory in which the procedures will be done and the techniques/procedures used to contain hazards and protect personnel. Protocols will be submitted on the specific forms developed by the IACUC, IBC, RSC, and Safety Services.

k. Training: Instruction given to all persons working in a laboratory to include:

(1) Information about rules, regulations and guidelines applicable to the designated activities;

(2) Basic safety information about laboratory work;

(3) Specialized safety information as required by the designated activities;

(4) Specialized, on-the-job training by the Principal Investigator or Supervisor applicable to the designated activities; and

(5) All laboratory workers must complete the 鈥淟aboratory Safety Essentials鈥� training course.

l. Chemical/Biological Inventory: A complete listing of chemical and/or biological materials in the possession of the Principal Investigator responsible for the laboratory space. The list shall include, but is not limited to, the chemical and/or biological material name or description, quantity or amount possessed, and physical form.

Program.

m. General Policies.

(1) All laboratory procedures shall be conducted in space approved for that purpose.

(2) Signs or markings with the words 鈥淎uthorized Personnel Only鈥� will be placed on all laboratory entrance doors opening to areas accessible to the general public.

(3) Access to laboratory must be restricted to authorized personnel only. Laboratory doors and any door opening into a corridor should never be propped open. They shall remain closed at all times and shall be secured even in the presence of workers.

(4) The PI shall contact Safety Services and provide a description of the anticipated activities. Safety Services shall advise the PI if the anticipated activities require approval by the IBC, IACUC, RSC, IRB, or other committee(s). If such approval is required, the PI shall submit a protocol to the appropriate committee. That committee shall review the protocol and, in consultation with Safety Services, shall be responsible for designating the type of training or precautions which will be required for laboratory workers and any special safety procedures which will need to be implemented in the laboratory. Any activities not requiring approval by these committees shall require review and approval by Safety Services of the activities, space and training of laboratory workers. Records pertaining to such approval shall be maintained by Safety Services. Amendments covering planned changes in protocol or procedures and laboratory workers shall be submitted to the original approval entity.

(5) Activities involving use of hazardous materials shall be approved by the appropriate oversight committee before any activity begins in the laboratory.

(6) All PIs shall provide a chemical/biological inventory to Safety Services upon initial assignment to a laboratory space, and shall provide an inventory update at least annually, or as required or is appropriate.

(7) All PI shall be qualified and credentialed as knowledgeable and trained in the laboratory activity and be capable of providing on-the-job training to personnel working in the laboratory. Credentialing will be performed by Safety Services or the appropriate committee with oversight responsibility.

(8) All persons working in the laboratory (including volunteers) shall receive the appropriate training and be certified for such training before being allowed to work in the laboratory.

(9) All records of training and approval of special activities shall be maintained in a central location under the overall supervision of the Department of Safety Services.

(10) This policy applies to all 香蕉直播 facilities. Implementation at individual facilities will require submission by the chief administrative officer at each site of an addendum defining responsibilities at that site under the aegis of the oversight committee and the Department of Safety Services in Lubbock.

n. Responsibilities:

(1) It is the responsibility of the departmental chair/unit supervisor to:

(a) Designate a PI to be responsible for laboratory space and the designated activities conducted therein;

(b) Provide each PI with a current copy of this policy and any subsequent revisions;

(c) Evaluate the PI on a regular basis to determine whether laboratory responsibilities have been met (including safety and security measures);

(d) Initiate corrective action as necessary;