Laboratory Relocation Policy. Overview 2. Laboratory Close Out Contacts..3. Initial Laboratory Close Out Checklist...3

Transcription

1 Laboratory Relocation Policy Due to the variety and amount of hazardous materials (biological, chemical, and radioactive) routinely present in biomedical laboratories, laboratory relocations have the potential to negatively impact the safety of staff, research and the environment as well as the violation of federal, state and local regulations. The following guidelines are intended to assist laboratory personnel in planning and executing laboratory relocations. Contents Overview 2 Laboratory Close Out Contacts..3 Initial Laboratory Close Out Checklist...3 General Lab Safety Close Out Checklist 4 Chemical Safety Laboratory Close Out Checklist..6 Biosafety Laboratory Close Out Checklist.9 Radiation Safety Laboratory Close Out Checklists 11 Medical University of South Carolina University Risk Management Modified on August 16,

2 Overview Laboratories within MUSC must be left in a state suitable for new occupants or for renovation activities. The vacating Principal Investigator (PI) is responsible for leaving laboratories in a state suitable for re-occupancy or renovation. The PI is responsible for ensuring the disinfection of equipment and counters, movement of equipment from the lab for surplus, repair, or relocation, and disposal of chemical, biological, and radioactive waste materials prior to vacating the space. Applicability The following procedure must be used whenever a MUSC laboratory will be vacated for any reason (i.e., renovation, relocation, or termination of research activities). Responsibilities Occupational Safety and Health Programs (OSHP) will provide proper guidance for laboratory closeout. OSHP will issue a final laboratory clearance for those vacated laboratories found to be compliant with these guidelines. Departments are responsible for ensuring all Principal Investigators follow these guidelines to ensure laboratory clearance by OSHP. Departments will be held responsible for the proper clearance of laboratory space, equipment and supplies belonging to PIs who fail to comply. Items left behind by vacating Investigators will become the responsibility of the Department Chair. Any costs incurred by OSHP for handling and disposal of discarded hazardous materials will be billed to the vacating Investigator s department / college. Principal Investigators are responsible for leaving laboratories in a state suitable for reoccupancy or renovation. PIs are responsible for ensuring the disinfection of equipment and counters, movement of equipment from the lab for surplus, repair, or relocation, and disposal of chemical, biological, and radioactive waste materials prior to vacating the space. The Principal Investigator is responsible for ensuring a safe work environment for laboratory personnel and complying with all applicable federal, state and local regulations and guidelines. Procedure Laboratory space cannot be re-occupied nor renovation work started until the space has been inspected and cleared by OSHP. Many tasks must be completed prior to the final OSHP close out inspection. The following checklists are to be used as guides to facilitate clearance of the laboratory. This manual will explain how to handle- Chemicals and Chemical Waste Biological Materials, Sharps, and Biohazardous Waste Radioactive Materials General Lab Close Out 2

3 Procedure The procedures detailed herein address the requirements for removing hazardous materials from the laboratory setting. Due to the various types of hazardous materials and the associated regulatory requirements, these procedures have been subdivided by into specific checklists for the pertinent safety offices. The appropriate checklist must be completed prior to vacating the laboratory. Submit a laboratory relocation notification to OSHP, Biosafety and Radiation Safety offices via the following online form: Laboratory Close Out Contacts: Office Name Phone # Address Occupational Safety and Health Programs (OSHP) Office Main Line (843) Lab Safety / Chemical Safety Chloe Backman (843) backmanc@musc.edu OSHP/Hazardous Waste Manager Bill Seaborn (843) Biosafety Officer Daniel Eisenman, Ph.D. (843) seabornw@musc.edu eisenman@musc.edu Radiation Safety Office Main Line (843) Assistant Radiation Safety Officer John Hardee (843) hardeejo@musc.edu Timeline Lab relocation involving Contact Minimum amount of time prior to relocation All lab relocations Notify OSHP (Main Line) 2 Weeks Labs using radioactive materials Radiation Safety (Main Line) 1 Month High risk chemicals (Defined on page 3 of chemical safety checklist) Chemical waste pickup Recombinant DNA, microorganisms, biological toxins OSHP Submit online pick up request Submit IBC termination form if leaving MUSC Termination%20Form.doc 2 Weeks 1 Week 1 Week 3

4 Lab Close-Out Checklist Date & Initial 1. Assign a Lab Contact (someone trained and familiar with the health and safety hazards involved) to coordinate the Lab Close-Out Procedure. Someone must be available for contact by OSHP and in charge of the move for your lab. 2. Notify OSHP of your intended laboratory close out / move by completing the Laboratory Close Out Notification Form. Provide the date and time you would like to schedule your final walkthrough once the lab has been properly cleaned and all chemical, biohazards, and radioactive material have been removed. If you have questions about this form or close out procedures please contact any of the individuals listed on the previous page. 3. Carefully inspect shared storage areas such as refrigerators, freezers, cold rooms, and flammable liquid cabinets, under sinks and under fume hoods. All items must be assigned to a responsible person. If items are left behind and the responsible person cannot be determined, the Department will assume responsibility for any necessary clean-up/disposal. 4. Fill out the appropriate checklists on the following pages for the hazards found in your laboratory. 5. If radioactive material is used in the laboratory a Radiation Safety Office Exit Survey must be scheduled and completed prior to lab move/close-out. To schedule the Exit Survey contact Radiation Safety Office ( ). 6. An OSHP representative will inspect your lab and sign the clearance sheet. As Principal Investigator, I attest my responsibility to leave my laboratory in a state suitable for re-occupancy or renovation. To the best of my knowledge all laboratory associated hazards have been removed from the following locations. Building and Room numbers Principal Investigator Signature Date Occupational Safety and Health Programs Date Building Manager / Building Engineer Signature Date Upon collecting the requisite signatures, copies shall be posted at the entrances to the lab to provide notification that the lab is safe for entry and ready for re-occupancy or renovation. 4

5 General Lab Close-Out Checklist (Page 1 of 2) 1. Remove any absorbent covering and tape from all lab surfaces, including fume hood surfaces. If contaminated with hazardous materials dispose of the materials appropriately. If radioisotopes were used in the hood, please obtain a wipe sample free of isotopes from Radiation Safety at If you are moving, freezers do not have to be emptied as long as contents will not shift during the move. Freezers must be locked and / or taped shut. Exterior surfaces of freezers (doors and handles) must be wiped down with 10% bleach freshly made or another EPA listed tuberculocidal disinfectant. 3. Refrigerators must be emptied before moving. All interior and exterior surfaces must be cleaned with soap and water and a 10% bleach solution. Exterior surfaces (doors and handles) must be wiped down with 10% bleach freshly made or another EPA listed tuberculocidal disinfectant. The doors must be locked or taped shut for the move. 4. Equipment A) Decontaminate surfaces of contamination prone equipment (e.g., refrigerators, incubators, water baths, centrifuges, etc. with 10% bleach freshly made or another EPA listed tuberculocidal disinfectant. If equipment is to be released to non-lab personnel, (e.g. movers, repair services, surplus property), the equipment must have an OSHP Decontamination memo attached verifying that the equipment has been properly decontaminated. B) Incubators and water baths must be drained of all standing water, including water inside the jacket. C) Old or damaged equipment that will not be moved to the new location needs to be completely wiped down, inside and out with 10% bleach freshly made or another EPA listed tuberculocidal disinfectant before disposal. NOTE: Bleach is corrosive. Allow 20 minutes of contact time to disinfect metal surfaces prior to rinsing with water or 70% ethanol to prevent rusting. It is not acceptable to leave any surface contaminated for equipment to be discarded. Contact Engineering and Facilities at if the equipment contains a compressor or refrigerant. It is unacceptable to dispose of equipment in the trash. Surplus: Surplus: 5. Empty and properly dispose of all materials from all drawers, cabinets, and fume hoods. Wipe down the surfaces of the fume hoods and cabinets where chemicals were stored. 6. Ensure that all microtubes, pipette tips, glass Pasteur pipettes, etc., that may be lying on the floor under equipment or in corners are properly disposed before vacating the lab. 7. Make sure all broken glass and other glass waste is put in labeled, rigid containers. 8. Place all disposable sharps (needles, syringes, blades, scalpels, etc.) in puncture resistant sharps boxes. Snap shut and deposit with biohazardous waste. For assistance with this section contact: Chloe Backman Tel Occupational Safety and Health Programs backmanc@musc.edu 5

6 General Lab Close-Out Checklist (Page 2 of 2) 9. Fume Hood Maintenance or Removal: Remove all chemicals from fume hoods before work or removal begins. Protocol for Removal/Work on Chemical Fume Hoods (a) Each investigator is responsible for making sure all chemicals are removed from fume hoods if work is to be done. (b) The Principal Investigator must submit a memo to OSHP stating that NO Perchloric Acid has been used in the fume hood. 1. If the fume hood is suspected or it is known that Perchloric Acid was used in a Non- Approved Fume Hood, a wipe sample for contaminates will be performed by Occupational Safety and Health. If the sample is positive for contaminates a wash down procedure will take place to rid any crystallization of the peroxides which was built up in a non-approved Perchloric Acid hood. This procedure usually takes 3-4 days including the wash down and analyzation. The cost of this procedure will be billed to the department whose occupants knowingly contaminated a Non-approved Perchloric Acid Fume hood. 2. Notify Radiation Safety at if radioactive material were used in the fume hood so that they may do a wipe sample to indicate whether radioisotopes are present in the fume hood. A memo will be written to this effect. 3. Each investigator is responsible for making sure all chemicals are removed from the fume hood if work or removal is to be performed. 4. If a hood has Asbestos present, the personnel performing work must be an asbestos certified worker. 10. Clean bench tops, shelves, cabinets and other lab surfaces where chemicals were stored or used to remove any residual chemicals with soap and water. 11. Label areas in cold rooms to identify those occupied by the relocating Principal Investigator. 12. When Laboratory is completely clear, housekeeping can perform a general cleaning. When this is completed, the Occupational Safety Laboratory Coordinator will sign the Laboratory exit report. 6

7 Chemical Safety Lab Close-Out Checklist (Page 1 of 3) 1. General Standards Minimize the number of chemicals that need to be moved. Dispose of chemicals that are no longer needed. Ensure all containers to be moved are clearly marked as to the contents and hazard. Containers must be in good condition and must close securely. Ensure the outside of the containers are clean and not contaminated with any hazardous materials. If so segregate these chemicals for disposal. 2. Unknown Containers Label any unmarked or unclearly labeled containers. Make every effort to identify any unknown substances since disposal of true unknowns is associated with high cost. If the contents of a container can not be identified segregate it for identification during waste collection. 3. Chemical Reuse Identify unopened chemicals that have not expired and will not be transferred to the new location. Such chemicals can be offered to neighboring labs. Donated chemicals must be removed from your chemical inventory and added to the receiving laboratory s chemical inventory. 4. Pick-Up Requests Submit online pickup requests for chemical waste three working days prior to the lab relocation. A hazardous waste disposal contractor will arrive to pick up chemical waste. Hazardous waste cannot be moved from one location to another. The presence of waste chemicals in your lab will delay final clearance by OSHP. 5. Chemicals Awaiting Disposal All chemicals that are not slated for transfer or relocation must be sent for proper disposal. Containers must be sealed and labeled with the MUSC hazardous waste or non-hazardous waste label. No chemicals should be put into the trash, poured into the sink or evaporated in a chemical fume hood. Designate a safe, conspicuous, well marked area to collect waste chemicals, keeping them properly segregated as prescribed in the Chemical Segregation section to facilitate collection by the disposal contractor. 6. Cold Storage Carefully inspect shared storage areas such as refrigerators, freezers, cold rooms, and flammable liquid cabinets. Old reagents must also be identified and disposed or moved to the new location. 7. Cold Storage Label areas in cold rooms to identify those occupied by the relocating Principal Investigator. For assistance with this section contact: Bill Seaborn Tel Hazardous Waste Manager seabornw@musc.edu 7

8 Chemical Safety Lab Close-Out Checklist (Page 2 of 3) 8. Small Compressed Gas Cylinders One time use small compressed gas cylinders will be removed for disposal or transported to the new location by OSHP. Designate a safe, conspicuous, well marked area to store cylinders prior to transport or disposal. Be sure to mark the cylinders as waste or to be moved. Any empty or unwanted reusable small compressed gas cylinders should be picked up by your gas supplier. Reusable small compressed gas cylinders that are to be transported to a new location will be moved by OSHP. 9. Large Compressed Gas Cylinders Designate a safe, conspicuous, well marked area to store cylinders prior to transport or disposal. Be sure that your cylinders remain properly secured in the old location prior to transport or disposal. Empty or unwanted reusable large compressed gas cylinders must be picked up by your gas supplier. Make arrangement with the gas supplier to transport large compressed gas cylinders to the new laboratory location. Prior to relocating cylinders, ensure the new location has adequate facilities to properly secure the cylinders upon arrival. 10. Chemical Segregation Separate chemicals according to hazard class to ensure incompatible chemicals are not transported in the same container. OSHP will assist you in segregating them for storage at the new laboratory location. Fisher, Baker and other chemical manufacturers use a color coded system for segregating chemicals. This may help you to separate them according to hazard class. Flammables and Combustibles (Red) Flammable Solids (Red) Corrosive Acids (White A) Corrosive Bases (White B) Poisons / Toxins (Blue T) Cyanides (Blue C) Oxidizers (Yellow OX) Peroxide Formers (Yellow PF) Water Reactives (Yellow WR) Organic Peroxides (Yellow OP) 11. Chemical Inventory Update your written chemical inventory as you pack. You will be required to provide OSHP with an updated inventory after occupying the new laboratory location. 12. Spill Clean-Up Have spill clean-up materials on hand before packing. Wear the proper personal protective equipment (gloves, lab coat, safety glasses or goggles). Ensure each chemical container is labeled and lids are on tightly and in good condition. Contact OSHP ( ) if spills occur. 13. Transport Carts Use sturdy carts with raised edges on all sides to contain boxes when moving chemicals. Be especially careful when entering or exiting elevators as the wheels of some carts may get stuck and cause carts to tip over. 8

9 Chemical Safety Lab Close-Out Checklist (Page 3 of 3) 14. Low Risk Chemicals OSHP considers Low Risk Chemicals as those that are not flammable, oxidizing, reactive, toxic or corrosive. Examples of such chemicals include buffers, salts and growth media. Lab personnel can move these items themselves as they do not pose a great risk should spillage occur. Lab personnel moving Low Risk Chemicals must be familiar with the hazards associated with the materials. Use sturdy boxes, deep trays or 5 gallon buckets with lids to transport chemicals. Cushion containers to prevent breakage and contain spills using compatible absorbent materials. Newspapers or paper towels are good cushions since they are absorbent and do not react with most chemicals. Pack boxes so they can be completely closed. Large 4-liter glass containers can be moved in carriers if they do not fit in boxes. Do not pack containers to the point where they are too heavy to lift. Packaging and transport of Low Risk Chemicals should only take place during normal business hours. 15. High Risk Chemicals OSHP considers High Risk Chemicals as those that are flammable, oxidizing, reactive, toxic or corrosive. Examples of such chemicals would be solvents, peroxides, cyanide, acids and bases. Lab personnel must not move these chemicals as they pose a great risk should spillage occur. OSHP will pack and transport these materials after they have been segregated as prescribed in the Chemical Segregation section. Packing containers and packing material will be provided by OSHP. A two week notice is required for this service. 16. Chemical Transport Personnel Independent movers contracted to move furniture and equipment must not move any type of chemicals. 9

10 Biosafety Lab Close-Out Checklist (Page 1 of 2) 1. Assess your biological materials (rdna, microorganisms, biological toxins, cell lines, tissues, organs, body fluids and biologically derived or contaminated media) and determine which materials will be moved to your new location, transferred to another investigator or disposed. 2. Investigators working with recombinant DNA, microorganisms or biological toxins must have Institutional Biosafety Committee (IBC) registrations. The registration must be amended through the ERMA system ( if relocating to new facilities within MUSC. Agents may be transferred to MUSC Investigators who have received prior IBC approval. IBC registered Investigators leaving MUSC must submit an IBC Termination Form ( to the IBC Administrator. 3. Transfer of CDC / USDA Select Agents (including toxins above regulatory limits) requires the notification and approval of the Biosafety Officer prior to the move. See Listing of Select Agentshttp:// 4. Transport or shipment of biological materials off campus, requires current shipping certification to ensure Department of Transportation (DOT) / IATA shipping regulations are followed. Individuals must have current training in order to package these items for shipment. The following link provides guidance for obtaining shipping training Institutional Animal Care and Use Committee (IACUC) protocols must be terminated or transferred to another Principle Investigators prior to leaving MUSC. Investigators terminating IACUC registrations must no longer have live animals when submitting the termination form. IACUC termination forms and change in Principal Investigator forms are available at the IACUC forms page. ( 6. Check cold rooms, freezers, and refrigerators for biological agents that could easily be forgotten. Old samples from past staff and students or inherited samples must be either disposed or marked for moving to the new location. Items left behind by vacating Investigators will become the responsibility of the Department Chair. 7. Properly dispose of all biological waste. Dispose of all solid media, supplies and waste in biohazard / infectious waste bags. Live cells, cultures, frozen stocks, etc. must be autoclaved prior to disposal. 8. Decontaminate all liquid biohazard waste by adding bleach to a final concentration of 10% by volume and allowing it 30 minutes of contact time before disposal down the drain with copious amounts of water. 9. Decontaminate all work surfaces with 70% ethanol, freshly prepared 10% bleach or another EPA listed disinfectant suitable for the agents utilized. 10. Place all disposable sharps (needles, syringes, blades, scalpels, etc.) in puncture resistant sharps boxes. Snap shut and deposit with biohazardous waste. For assistance with this section contact: Daniel Eisenman Ph.D. Tel Biosafety Officer eisenman@musc.edu 10

11 Biosafety Lab Close-Out Checklist (Page 2 of 2) 11. Equipment used with biological materials a) Decontaminate surfaces of contamination prone equipment, e.g. refrigerators, incubators, water baths, centrifuges, with 70% ethanol, freshly prepared 10% bleach or another EPA listed disinfectant suitable for the agents utilized. NOTE: Bleach is corrosive. Allow 20 minutes of contact time to disinfect metal surfaces prior to rinsing with water or 70% ethanol to prevent rusting. b) Incubators and water baths must be drained of all standing water including water in water-jacketed incubators. c) Equipment to be discarded must have all surfaces disinfected. Equipment being submitted to Surplus must be accompanied by the following form Biological Safety Cabinets a) Disinfect and remove the contents of the biological safety cabinet. b) Disconnect the tissue culture vacuum flask and decontaminate by adding bleach to a final concentration of 10% and allowing it to sit 30 minutes before disposal down the drain. c) Disinfect all accessible surfaces within the biological safety cabinet with 70% ethanol, freshly prepared 10% bleach or another suitable EPA listed disinfectant. NOTE: Bleach is corrosive (See #36). d) Re-certify any relocated biological safety cabinets before use. The MUSC Biosafety Cabinet Service Program can arrange for the relocation, maintenance, repair and recertification of biosafety cabinets. Contact the Biosafety Officer for assistance. 13. Ultra low temperature (-80 o C) freezers used for storage during lab relocations do not have to be emptied prior to moving if the contents will not shift during the move. Freezers must be locked. Microorganisms stored within the freezer must be secured within primary and secondary containment. Secondary containment must be leak-proof and labeled with a biohazard sticker. If transporting organisms classified as Risk Group 2 or greater, a Biosafety Placard ( must be posted on the freezer with the agent s name and PI s contact information. 14. All biological materials must be transported within MUSC utilizing primary and secondary containment. The primary and the secondary containers must be leak proof. The secondary container must contain enough absorbent material to absorb the entire contents of all the primary containers within. The outside of the secondary container must have the biohazard symbol and a label containing the name of the PI and the new laboratory room number. These packages must be moved by lab personnel only. 11

12 Radiation Safety Prior to an investigator beginning use of Radioactive Materials he/she must be licensed to do so at the Medical University of South Carolina. If an individual is licensed and wishes to move from one licensed area to a new area he/she will have to follow the lab move procedure. Once the lab has moved the radiation safety office will send a member of the staff to the lab to assist with lab set up as follows; 1. Proper Caution signs will be placed on lab entry ways. 2. Instructions will be provided as to how to properly label work areas. 3. Instructions will be provided regarding proper paperwork that must be submitted to the Radiation Safety Office. 4. Instructions and assistance will be provided in regards to procurement of Radioactive Materials. 5. Examples of the Radioactive Materials Disposal sheet, Sewer Disposal sheet, Wipe Test log, and Waste Disposal documentation will be reviewed. 6. Examples of GM Meters and recommendations for detection equipment will be given. 7. Instructions will be provided regarding procedures to perform in the event of a spill. 8. Instructions will be provided regarding Transfer of Radioactive Materials internally and externally. 9. Instructions will be provided regarding procedures to perform in the event that the lab will move or the PI transferred to a new location. For assistance with this section contact: John Hardee Tel Radiation Safety Officer hardeejo@musc.edu 12

13 Radiation Safety - On Campus Relocation Procedure 1. Contact the Radiation Safety Office (RSO) ( ) as soon as you know a tentative move date and arrange for the Radiation Safety Exit Survey and New Lab set up. 2. At least 1 month prior to the move, amend your current Radioactive Materials Authorization License to add new laboratory(s). (a map must be provided to the RSO) 3. Package all Radioactive Materials (RAM) that can be disposed of as RAM waste and request a RAM waste pickup. For Radioactive Waste Pick Up Form see Radiation Safety Website Pickup request. 4. Any chemical fume hoods where Iodine-125 or Iodine-131 were utilized must be surveyed by RSO. 5. RSO can assist with the move of radioactive materials. 6. Inform the RSO of any RAM use areas that will not be vacated but the movers will need to access. 7. Equipment - If equipment used for storage of RAM or used with RAM procedures will be moved, request the RSO perform a special survey of the equipment. This survey must be done prior to moving the equipment to the new lab or to surplus. If equipment is to be released to non-lab personnel (e.g. movers, repair services, surplus property) the equipment must have a letter verifying decontamination. 8. At no time may the PI move Radioactive Materials on public highways in a vehicle. 9. Prior to move day, the RSO will perform a commissioning survey of the new laboratory(s). (Note: For new buildings, the RAM sign will not be posted until just prior to move in day; if no RAM needs to be moved into the laboratory on the move in day, the RAM sign will be posted once the move is completed-radioactive Materials moved into the lab). 10. After the old lab is vacated, the RSO will perform a Radiation Exit Survey. 11. If the lab is found to be contaminated the PI must decontaminate all areas prior to release. 12. Once a final survey indicates no RAM and no RAM contamination, the RSO will send correspondence to the Authorized User stating decommissioning is complete. 13. A letter will be generated by the RSO and sent to the PI, the PI s Department, as well as Physical Plant. 14. For the final step, the RSO will amend the authorization to add the new laboratory(s) and delete the vacated laboratory(s). 13

14 Radiation Safety - Off Campus Relocation Procedure 1. At least 1 month prior to the move/leaving the University the PI must contact the RSO to notify him that the PI will be leaving. 2. The PI must leave in a Departmental Account sufficient funds to cover waste disposal and lab decontamination in the event that the lab is contaminated beyond the scope that the PI and the Radiation Safety Office can safely/adequately decontaminate. 3. Package all RAM that can be disposed of as RAM waste and request a RAM waste pickup. For Radioactive Waste Pick Up Form see Radiation Safety Website Pickup request. 4. All Radioactive Materials that the PI wishes to ship to the new facility must be handled through the Radiation Safety Office. 5. The PI must provide proper Type A shipping containers for shipping. 6. All Radioactive Materials must be shipped through a licensed carrier and the cost for shipment will be the responsibility of the PI. 7. The PI must provide the Radiation Safety Office a copy of the license or the contact information for the Radiation Safety Officer at the new facility in order for Radiation Safety to ship to that facility. 8. All equipment that has been used with Radioactive Materials must be surveyed prior to packaging/shipment to the new facility or being sent to surplus. 9. The PI must perform and document a survey of the lab prior to leaving the University and provide this information to the RSO. 10. The Radiation Safety Office will perform a preliminary survey prior to the PI moving out of the lab to determine if any contamination is present. 11. All contaminated areas must be decontaminated by the PI prior to departure from the University. 12. Once the lab has been completely emptied the RSO will perform a final exit survey. 13. Upon determination that the lab is clean the RSO will generate a letter documenting that the lab is safe for renovation, reuse, or demolition according to the Departmental plan. 14. All documentation will be maintained in the Radiation Safety Office. 15. A copy of the letter will be sent to the PIs Department and to Physical Plant/Facilities and Engineering. 14