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EXIT PROTOCOL FOR UBC PRINCIPAL INVESTIGATORS
In the next few years a significant proportion of the research
faculty will be leaving UBC. In order to ease the transition between
the previous and the new tenants of the research facilities, HSE
has drafted a proposed protocol to facilitate the changeover.
Further heightening the need to ensure a smooth transition is
the advent of WHMIS, provincial and federal environmental regulations,
Atomic Energy Control Board Regulations and MRC Guidelines for
Biohazards. These regulations have made it mandatory that principal
investigators decommission laboratories to ensure that the legal
and ethical expectations associated with such work are met.
The purpose of the following protocol is to provide a framework
for Department heads to develop a site specific exit protocol
for research faculty under their supervision. Properly applied,
an exit protocol ensures that:
- Departmental policies and procedures are followed.
- Unsafe conditions are eliminated.
- A proper clean-up is performed.
- Lab equipment is properly disposed/recycled.
- Hazardous materials are properly disposed/recycled.
- Work surfaces are free of contamination.
- Regulatory requirements are met.
Notification
When a faculty member informs their Department head of their intentions
to leave UBC, (suggested minimum three months notice) the Department
head shall provide a copy of the Departmental exit protocol. It
is suggested for purposes of due diligence that the date of this
information transfer be documented. It is then the responsibility
of the department head to monitor that the faculty member follows
all the steps in the protocol to completion, including all requirements
for documentation.
Checklist
A checklist will provide a simple method for the Department head
to confirm the protocol has been completed. The faculty member
shall submit a completed exit protocol checklist to the department
head prior to departure. The department head shall keep a copy
and a copy shall also be provided to the faculty member. A generic
checklist is available from HSE and Department heads may wish
to modify and enhance any aspect of the list.
EXIT PROTOCOL FOR UBC PRINCIPAL INVESTIGATORS
[HSE: June, 2006]
Procedure
When the primary researcher or supervisor of a laboratory leaves
or decommissions a laboratory, the following procedures shall
be followed.
- General
- A current inventory of all hazardous materials must be
completed.
- All unknowns must be identified and appropriately labeled.
- All chemicals should be removed from the laboratory,
by transferring to another primary researcher/laboratory
supervisor, or by disposal through the Environmental Services
Facility.
- The Departmental Safety Committee should inspect the
laboratory to ensure removal of all material and approve
the removal by signing the inventory form.
- A copy of the approved inventory list should be sent
to the Departmental Head or Director. It is the responsibility of
the Department Head or Director to ensure that adequate procedures
are followed for the decommissioning of laboratories.
- Transfer of chemicals to another primary researcher/laboratory
supervisor
All materials transferred must be labeled according to WHMIS requirements and
the receiving party must obtain appropriate Material Safety Data Sheets. For
further information contact the University Occupational Hygiene Officer, 604-
822-2643.
Some of the materials may be forwarded to the University Chemical Exchange
Program for future use. Contact the ESF at 822-6306 for further information.
- Disposal of chemicals
The identity of all materials must be established before disposal. If there are
unidentified materials, contact Health, Safety and Environment to arrange for
materials to be classified for waste disposal purposes; there will be a cost
associated with this process (~$100.00 - ~$150.00/hour).
A chemical disposal inventory form must be completed for all chemicals ready for
disposal, and forwarded to the Department of Health, Safety & Environment.
Following approval by ESF staff, the materials must be packaged according to
the instructions provided and then arrangements are to be made with ESF at
822-6306, for pick-up of the material.
Return compressed gas cylinders to suppliers.
- Radioisotope Licence De-activation and Laboratory Decommissioning
Required from the Licensee:
- Memo to Radiation Safety Office (RSO) stating intent to discontinue
the isotope licence.
- Complete a set of wipe tests for every laboratory licensed
for isotope use.
- Record of proper disposal of all isotopes on hand (this
can include a gift of remaining isotope to another researcher
that is licensed for that nuclide).
- Completion of a yearly isotope inventory (from RSO).
- If the researcher is leaving the University, or does
not intend to re-activate the licence at some future date,
all isotope purchase, usage, disposal and contamination
control records must be forwarded to the Radiation Safety
Office.
Following the completion of the above steps, the Radiation Safety
Officer will remove all signs. Thereafter, a letter will be
issued to the researcher stating that the licence is no longer
active. Decommissioning of laboratory space is not complete
until verification by the Radiation Safety Office.
- Biohazard Laboratory Decommissioning
- Notify Biosafety Office (604-822-7596) that biohazard protocols are
to be concluded.
- Record transfer of Biohazardous materials to the inventory
of another researcher.
- Terminate all Biohazards not transferred to the inventory
of another researcher.
- Decontaminate all working surfaces.
- Conclude liquid nitrogen delivery contract.
EXIT PROTOCOL CHECKLIST
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version of this checklist
Date____________________
| Have you |
Yes |
No |
N/A |
| 1. Created a complete inventory of all hazardous materials
in the laboratory? |
|
|
|
| 2. Has the department head/administoration received a
copy of the inventory? |
|
|
|
| 3. Have all unknowns been identified and properly labeled? |
|
|
|
| 4. Are MSDS sheets available for all chemicals? |
|
|
|
|
5. Have the chemicals been transferred to a another researcher's
inventory or to the Environmental Services facility?
|
|
|
|
| 6. Have compressed gas sylinders been returned to the
suppliers? |
|
|
|
| 7. Has the Radiation Safety Office (RSO) been notified
of your intent to decommission the radioisotope licence? |
|
|
|
| 8. Has a complete set of wipe tests been performed in
all licensed areas and submitted to the RSO? |
|
|
|
| 9. Have the radioisotopes been disposed of or transferred
to another licensee? |
|
|
|
| 10. Has an annual inventory record been submitted to the
RSO? |
|
|
|
| 11. Have all radiation inventory and contamination control
records been submitted to the RSO? |
|
|
|
| 12. Has the Biosafety Officer been notified of your intent
to terminate work with Biohazards? |
|
|
|
| 13. Has biohazardous materail been disposed of transferred
to another researcher? |
|
|
|
| 14. Are all working surfaces decontaminated? |
|
|
|
| 15. Has the liquid nitrogen contract been terminated? |
|
|
|
| 16. Has specialized lab equipment been safely deenergized/recycled/disposed? |
|
|
|
| 17. Has the Safety Committee inspected the laboratory? [attach Exit Safety Inspection Report] |
|
|
|
Scientist:
name:________________________________
signature:_____________________________
date:________________________________ |
Department Head/Administrator;
name:________________________________
signature:_____________________________
date:________________________________ |