Rule 3352-7-27 | Exit Policy for the Closeout/Decommissioning of University Laboratories.
(A) Purpose
University investigators often use hazardous chemicals or agents as part of their laboratory research. Through requirements established in the "Chemical Hygiene Plan, Biosafety Manual, Radiation Safety Manual," and regulations instituted by federal and state agencies, investigators must properly handle and control these chemicals and agents to protect persons and the environment. This policy extends the requirement for investigators to maintain control of these materials and potentially contaminated spaces through the process of closing out their laboratory. A principle investigator who permanently vacates laboratory space as part of relocating to another laboratory at the university, transferring to another university, retiring, or suspending laboratory operations for any other reason must ensure that all environmental and occupational health and safety regulations are met to assure a safe work area for future users.
(B) Applicability
This policy applies to the closeout/decommissioning of any university laboratory that had operations dealing with hazardous materials. For the purpose of this policy, hazardous material includes chemicals, radioactive materials, and biological, infectious, or zoonotic agents or toxins. This policy also applies to hazardous materials belonging to the vacating principal investigator, but stored in a shared use or storage space (e.g., cold room, freezer, or stock room).
(C) Responsibilities
(1) Principal investigator
The principal investigator (PI) is a faculty or staff member serving as the responsible individual of the laboratory. The PI retains responsibility for proper management of hazardous materials and contaminated equipment or laboratory surfaces. At least one month before vacating the laboratory space or as soon as the decision is made, the PI will inform the director of environmental health and safety (EHS) of the planned move. The PI will meet with the director of EHS or his/her representative to discuss the close out process. If necessary, the department chair may be involved in the discussion. The director of EHS will provide the PI a copy of the "Laboratory Clearance Checklist" which will be used to complete the "Exit Clearance" process (see paragraph (E) of this rule).
(2) Department chair or director
The chair or director is accountable for laboratory space assigned to the department. The chair or director must ensure the director of EHS is timely informed of planned laboratory closeouts. In the event services beyond those routinely performed by EHS are required, such that an outside contractor is needed, the responsible department will be charged for purchased services. Any regulatory action or fines resulting from improper management of hazardous materials will be charged to the responsible department.
(3) Environmental health and safety (EHS)
EHS will work with the PI to develop a management plan for the proper management and disposal of hazardous material and with developing procedures for the required decontamination of equipment or laboratory surfaces. EHS is responsible for the costs associated with the disposal of hazardous materials that have been managed as required under applicable procedures. EHS staff will perform the final inspection of a vacated laboratory, along with the PI as described in paragraph (E) of this rule, and will release the laboratory for future use once all requirements have been met.
(4) Laboratory animal resources (LAR)
The director of LAR is responsible for the management of all controlled substances regulated by the federal drug enforcement agency (DEA) and for the incineration of all animal waste not meeting the Ohio environmental protection agency's (OEPA) definition of infectious waste.
(D) Procedures
Principal investigators shall follow the procedures in this section to manage hazardous material when exiting a laboratory. Any equipment or laboratory surface that is contaminated with any hazardous material must be decontaminated as described in this paragraph.
(1) Chemicals. References: rule 3352-7-20 of the Administrative Code.
(a) Any chemical distributed to you as a DEA controlled substance must be returned to the director, laboratory animal resources, prior to exiting the laboratory.
(b) Chemicals can be transferred to other laboratories within the department, or other university departments, with the acknowledgement of EHS and updating the laboratory chemical inventory of the accepting location. Contact EHS prior to transference of any chemicals.
(c) Hazardous chemicals transported off campus must comply with applicable U.S. department of transportation (DOT) regulations by following EHS's procedures on transportation of hazardous materials. These procedures can be accessed on the EHS website at http://www.wright.edu/admin/ehs.
(d) Chemicals you wish to have managed by EHS must be properly containerized and labeled. Proper labeling requires the chemical name of each chemical to be listed on the container. If a container has a mixture of chemicals, each chemical must be listed with its relative percentage. Chemical formulas, abbreviations, or trade names are not acceptable. For any commercial chemical product that is not labeled with its chemical name, a "Material Safety Data Sheet" must be requested from the company and supplied to EHS with the chemical. Contact EHS to arrange for chemical pick up.
(e) If the investigator is leaving the university, return the WSU chemical hygiene plan to EHS.
(2) Radioactive material. Reference: "University Radiation Safety Manual" (RSM)
Authorized users must:
(a) Inform the radiation safety officer (RSO) at least two weeks prior to the laboratory closeout.
(b) Terminate their radioactive materials protocols (section of 2.6.4 of the RSM).
(c) Ensure laboratory facilities and equipment are free of contamination (sections 2.18 and 2.19 of the RSM).
(d) Ensure all radioactive materials, radioactive waste, and potentially contaminated equipment or surfaces are properly labeled (sections 2.17 and 2.24 of the RSM).
(e) Returned all remaining radioactive materials and dispose of radioactive waste to the radiation safety office (sections 2.24 of the RSM).
(f) If the authorized user is leaving the university, return the "Radiation Safety Manual," personnel dosimeters, survey meters, radiation protection equipment, and shielding devices to the radiation safety office.
(g) Inform the RSO if any radioactive material will be transferred to another authorized user, another location on campus, or to another licensed institution (section 2.14.3 and 2.15 of the RSM).
(h) Schedule a final laboratory radiation survey (and bioassay, if appropriate) with the radiation safety office.
(3) Biological and infectious material
References: Wright state university's "Institutional Biosafety Manual"; Wright state university's "Infectious Waste Management Guide"; Title 42 Code of Federal Regulations Part 73. If you are leaving the university and were issued an "Institutional Biosafety Manual," return it to the university institutional biosafety officer.
(a) Select agents:
(i) Certain biological material and toxins considered select agents (se 42 CRF 73.4 and 73.5) cannot be transferred to other university personnel or transported off campus without prior approval from EHS , the institutional biological safety officer, the department of health and human services, and/or the United States department of agriculture.
(ii) The disposal of select agents, if meeting the OEPA definition of infectious waste (see paragraph (D)(3)(b) of this rule), shall be managed as described in the section for infectious waste. Select agents not meeting the definition of infectious waste must be handled on a case by case basis. Contact the institutional biological safety officer for assistance.
(b) Infectious waste:
(i) All waste material meeting the OEPA definition of infectious waste must be collected by EHS except in cases when liquid infectious waste cultures can be treated with bleach and disposed down the drain. OEPA's definition of infectious waste can be found in the "Infectious Waste Management Guide," appendix D in the WSU "Institutional Biosafety Manual," or on the EHS website at http://www.wright.edu/admin/ehs. In all cases, EHS must be notified. Prior to EHS picking up any infectious waste, or when treating liquid infectious waste cultures, all waste must be managed as described in the "Infectious Waste Management Guide."
(ii) In no cases shall material meeting the OEPA's definition of infectious waste be autoclaved and disposed as regular trash or sent to laboratory animal resources for incineration.
(iii) Contact environmental health and safety to obtain any needed infectious waste boxes or to schedule a pick up of infectious waste.
(c) Animal and human tissue:
(i) If tissue is held in a liquid preservative, tissue and liquid must be separated.
(ii) Liquid preservative shall be managed as described in the chemicals paragraph of this rule.
(iii) Tissue meeting the OEPA definition of infectious waste must be collected by EHS. Prior to EHS picking up any infectious waste it must be managed as described in the "Infectious Waste Management Guide" of the WSU "Institutional Biosafety Manual" (appendix D). OEPA's definition of infectious waste can be found in the management guide which can be viewed on EHS's website: http://www.wright.edu/admin/ehs/.
(iv) Tissue not meeting the definition of infectious waste shall be collected and sent to laboratory animal resources for incineration.
(d) Toxins:
(i) Toxins must be handled on a case by case basis. Contact EHS for instructions.
(ii) Toxins considered a select agent will be managed for disposal, transfer, or transport according to 42 CFR 72 and 73.
(4) Laboratory equipment and surfaces
(a) Any laboratory equipment or laboratory surface that is contaminated with a hazardous material must be decontaminated prior to exiting the lab or distribution of the equipment. Proper decontamination requires the wipe down of all contaminated surfaces with a solvent or cleaning agent capable of removing the contaminant. Any equipment that contains a hazardous material integral to the operation of the equipment (i.e., oil, mercury, refrigerant, asbestos...) must have the hazardous material removed prior to disposal. The exception to this is if Wright state university's excess and surplus management department (ESPM) plans to sell the equipment as useable.
(b) Any laboratory equipment that is contaminated with, or contains, radioactive material must go through a specific clearance process initiated by the radiation safety office. Refer to the radioactive material section of this policy for guidance.
(c) ESPM must manage all equipment for disposal or resale. Refer to Wright state university's "Wright Way Policy Manual Policy 5403" for the requirements of ESPM. Specifically, policy 5403.6(e) stipulates the requirements for handling equipment that contains or is contaminated with a hazardous material. These requirements must be satisfied.
(E) Laboratory exit clearance
(1) After all hazardous material has been managed as described in this policy; contact EHS, (937) 775-2215, to set up a laboratory clearance meeting. The meeting shall be held in the laboratory and attended by the principal investigator and an EHS representative(s). Either the principal investigator or EHS may request that the department chair or director attend the meeting.
(2) The EHS representative(s), with assistance from the principal investigator, will complete the EHS "Laboratory Clearance Checklist." The checklist will be signed by the principal investigator and the chair or director of the department or administrative unit after which the lab will be considered safe for reuse by another investigator. The completed and signed "Clearance Checklist" will be kept on file in EHS permanently.
Last updated June 11, 2021 at 9:10 AM
Supplemental Information