Procedure 10:
Laboratory Compliance Oversight

Policy

Laboratory Compliance Audits

Environmental Safety Facility staff perform laboratory health and safety audits in order to assist laboratory workers in maintaining a safe and healthy workplace. ESF staff also assist in correcting issues of non-compliance found during audits, but it is the responsibility of the laboratory personnel to assure that all problems discovered during an audit are satisfactorily addressed within a reasonable time frame.

During a routine audit, ESF staff and laboratory personnel will address and correct any issues of noncompliance with the EMP that can be corrected at that time. If the compliance cannot be achieved immediately, a compliance schedule will be determined and documented on the audit form. Designated laboratory personnel will respond to ESF staff in writing once the problem has been corrected. A follow-up inspection of the lab will occur if more than a written response is necessary to assure compliance.

Laboratory Compliance Oversight

If the lab supervisor does not correct issues of noncompliance following the first audit, ESF staff will re-inspect the lab and notify the Department Chair in writing. If after 90 days, the problem persists, ESF staff will issue a report to the Vice Provost for Research as well as the Chemical and Biological Safety (CBS) Committee for further action.

In the case of an imminent danger to life, health or the environment, the Chemical and Biological Safety Committee is authorized to immediately order the cessation of the hazardous activity and close down laboratory activities until such activity has ceased and responsible individuals have taken adequate measures to correct the situation and prevent recurrence of the noncompliance.

Plan

Who:

ESF staff visit each lab to verify the lab supervisor and establish an audit schedule. ESF staff will conduct the audit with assistance from the laboratory supervisor or designee.

It is the laboratory supervisor's responsibility to assure that problems identified in the audit are addressed by the deadlines given by ESF staff. In case of shared labs, this responsibility will rest with the department chair or their designee.

Department chairs designate a laboratory supervisor for each laboratory room within their department (Procedure 8). ESF will record this on the UVM Audit Form during the periodic audit of laboratory operations.

When

ESF staff will audit laboratories annually.

Laboratory Supervisors will respond to the audit within the timeline established in the audit.

The Vice Provost, CBS Committee and Department Chairs will begin working with the lab supervisor upon notification of non-compliance issues.

Where

UVM laboratories are defined by their physical extent and may include more than a single room in the same building and under the same supervision. All UVM laboratories are covered by the requirements of the Laboratory Environmental Management Plan.

Procedure

Audit Form

ESF staff will periodically revise this form to most appropriately address hazard, risk and regulatory focus. Audit forms will reflect specific portions of the EMP, and may include review of training documentation, completed HCOC surveys or laboratory self inspection forms.

Audit Response Form

Records

The records of the ESF audits are maintained by the ESF staff for use by upper administration, ESF staff and auditors. Audit information will be used to update and maintain the ESF's roster of campus laboratories and supervisors.

Laboratory inspection response forms are maintained by the ESF. These are available to upper administration, ESF staff, UVM facilities planners and others to resolve issues related to the laboratories.