EXIT PROTOCOL for UBC Principal Investigators

EXIT PROTOCOL for UBC Principal Investigators

May 2016

With the advent of WorkplaceHazardousMaterialsInformationSystem(WHMIS);ProvincialandFederalHealth,Safety andEnvironmentalregulations;theCanadianNuclearSafetyandControlAct(2000);HealthCanada andCanadianFoodInspectionAgencyGuidelinesforworkingwithbiohazardousmaterials, and UBC Policy 9 on Hazardous Materials Management, the need for Principal investigators to decommission laboratories to ensure that the legal and ethical expectations associated with such work are met became mandatory.

The purpose of the following protocol is to provide a framework for Administrative Heads of Units to develop a site-specific exit protocol for research faculty and staff under their supervision that are leaving the University of British Columbia. It also provides for a proper lab decommissioning process, prior to renovation or transfer of lab occupancy. Properly applied, the protocol ensures that:

• Unsafe conditions are eliminated;
• A proper clean-up is performed;
• Lab equipment is properly decontaminated and disposed of or recycled;
• Hazardous materials are properly disposed of or recycled/reused;
• Work surfaces are free of contamination;
• The health and safety of researchers is protected;
• University policies and Departmental procedures are followed; and
• Regulatory requirements are met.

Notification

Itis recommendedthatfacultyor staffmemberinform theirAdministrative Headof Unitoftheir intention to leave UBC threemonths in advanceof the anticipated departuredate. The Administrative Headof Unitshall then provide a copyof theDepartmental ExitProtocol andinform theDepartmentof Risk ManagementServices of theresearchers intentto leave theUniversity.The date of this information transfershouldbe documented. Itis then the responsibilityof theAdministrative Headof Unittoensure thatthefacultyor staff memberfollows all thesteps in theprotocol to completion, includingall requirementsfordocumentation.

Checklist

A checklistwill provide a simple methodfortheAdministrative HeadofUnitto confirm thattheprotocol has been completed. Thefacultyorstaff member shall submit a completed exitprotocol checklist to theAdministrative Headof Unitprior to departure. TheAdministrative Headof Unitshallretain a copy andone shall also be providedto thefacultymember.

Procedure

When theprimary researcher or supervisor of a laboratoryleaves or decommissions a laboratory,thefollowingprocedures shall be followed:

General

1.A currentinventory of all hazardous materials mustbecompleted.

2.All unknowns mustbe identifiedandappropriately labeled.

3.All chemicals should beremoved fromthelaboratory bytransfer to another primary researcher/laboratorysupervisor,or by disposal through the Environmental Services Facility(ESF).

4.All solidwaste andglass waste containers should beemptiedandall equipmentnot transferredto thefutureoccupantof thespaceshould be removed.

5.Fume-hoods, biosafetycabinets, glove boxes andlabbenchesmustbe decontaminated andcleaned.

6.Special arrangementsmustbe made for thedisposal of potentially explosive materials andlecturebottles of hazardous gases (contact ESF at 26306for assistance)

7.TheLocal Health andSafetyCommitteeshould inspectthelaboratoryand demonstrateapproval of theprocess bysigningtheinventory form.

8.Anapproved inventory formshould besentto theAdministrative Headof Unitor Director. Itis theresponsibilityof theAdministrative Headof Unitor Director to ensurethatadequate proceduresarefollowedforthe decommissioningof laboratories.

9.In thecaseof buildingdecommissioning,or when thearea isto be renovated, or in swingspaces, thebuildingmanagershould participate in thelab inspection andapprovelabdecommissioning.

Transferof chemicals to another primary researcher or laboratory supervisor

All materials transferredmustbe labeledaccordingto WHMIS requirementsandthe receivingpartymustobtain appropriate Material SafetyData Sheets. For further information please contacttheChemical SafetyandOccupational HygieneAssociate at604-822-2273.If you wish to transfer radioactivematerials to another licensee pleasecontacttheRadiation SafetyAdvisor at 604-822-7052.

Someof thematerials maybe forwardedto theUniversityChemical Exchange Program for futureuse. ContacttheEnvironmental Services Facility(2-6306)

Disposal of Chemicals

Theidentityof all materials mustbe establishedbeforedisposal. Ifthereare unidentifiedmaterials, contacttheEnvironmental Services Facilityto arrange for materials to beclassifiedforwaste disposal purposes; therewill be a cost associated with this process ($100.00- $150.00/hour).

Makespecial arrangementsforthedisposal of potentially explosive materials or lecturebottles of hazardous gases by ESF approvedcontractor (contact ESF at 2-6306). Disposal costsareto bepaid bythe generator.

A chemical disposal inventory formmustbe completed for all chemicals readyfor disposal andforwardedto theDepartmentof RiskManagementServices. Following approval by ESF staff, thematerials mustbe packagedaccordingto theinstructions providedandthen arrangementsareto bemade with ESF at 822-6306for pick-up of thematerial.

Returncompressedgas cylinders to suppliers.

RadioisotopePermit & Laboratory Decommissioning

Requiredfrom theLicensee:

1.Memo to Radiation SafetyOffice(RSO) stating intentto discontinuethe radioisotope permit.

2.A complete setof wipe tests for each laboratory/roomlicensedforisotope use,regardless of radiation use,within thespace.Pleaserefer to your permitandassociated amendmentsforthelistof permittedrooms.

3.Record of properdisposal of all isotopes on hand. This can include a transfer of remainingisotopetoanother researcher thatis licensedforthat materialor totheRadiation SafetyOffice.

4.Completion of a yearly isotope inventory (obtainedfrom theRSO).

5.All isotope purchase,use,disposal andcontamination controlrecords must be transferredto theRadiation SafetyOffice.

Followingthe completion of theabove steps, Radiation SafetyOfficestaff will remove all signs andall records will be transferredto theRSO. Thereafter, a letter will be issuedto theresearcher, andthedepartmentheadif requested, stating thatthelicense is no longeractive. Decommissioningof laboratory spaceisnot complete untilall steps have been verifiedby theRadiation Safety Office.

Biohazard Laboratory Decommissioning

1.NotifytheBiosafetyOffice(604-822-9527) andtheOfficeof Research

Services thatthebiohazard protocols areto beconcluded andbywhatdate.

2.Record transfer ofbiohazardousmaterials to theinventory of another researcher.

3.Terminate all biohazards not transferredto theinventoryof another researcher.

4.Decontaminate all workingsurfaces.

5.Conclude liquid nitrogendelivery contract.

EXITPROTOCOLCHECKLISTDate:

Haveyou: / Yes / No / N/A
1.Createda completeinventoryofallhazardousmaterialsin thelaboratory?
2.HasAdministrativeHeadofUnitreceiveda copyofthe inventory?
3.Haveallunknowns(chemicals,etc.)beenidentifiedand properlylabeled?
4.Arrangementsweremadeforthedisposaloflecturebottles ofhazardousgasesandpotentiallyexplosivechemicals
5.AreMSDSsheetsavailableforallknownchemicals?
6.Havethechemicalsbeentransferredtoaanother researcher'sinventoryortotheEnvironmentalServices Facility?
7.Havecompressedgascylindersbeenreturnedtothe suppliers?
8.HastheRadiationSafetyOffice(RSO)beennotifiedofyour intenttodecommissiontheradioisotopepermit?
9.Hasacompletesetofwipetestsbeenperformedinall licensedareasandsubmittedtotheRSO?
10.Havetheradioisotopesbeendisposedofortransferredto anotherlicensee?
11.Hasanannualinventoryrecordbeensubmittedtothe
RSO?
12.Haveallradiationinventoryandcontaminationcontrol recordsbeensubmittedtotheRSO?
13.HastheBiosafetyOfficebeennotifiedofyourintentto terminateworkwithBiohazards?
14.Hasbiohazardousmaterialbeendisposedofand transferredtoanotherresearcher?
15.Areallworkingsurfacesdecontaminated?
16.Hastheliquidnitrogencontractbeenterminated?
17.Hasspecializedlabequipmentbeensafely decontaminated/de-energized/recycled/disposed?
18.HastheSafetyCommitteeinspectedthelaboratory? [attachExitSafetyInspectionReport]
19.Ifyouwillbetransferringtoanewlaboratoryorwork
area,hasRMSbeenprovidedwithupdatedinformationforthe hazardinformationdoorsigns,specificallyhazardinformation andemergencycontactinformation?

WhenaPIretires,closesanentirelabormovestoanotherbuilding,theformmustbe signedbelowandforwardedtoRiskManagementServicesforapproval.

PrincipalInvestigator:AdministrativeHeadofUnit:

Name:

Name:

Signature:

Signature:

Date:

Date:

SafetyCommitteeChair:FacilityManager:

Name:

Name:

Signature:

Signature:

Date:

Date:

WhenaPIleavesalab,butthespacewillstillbeoccupiedbythesamedepartment,the incomingPIacceptsthelabandtheinventoryinitscurrentcondition.

OutgoingLaboratorySupervisorIncomingLaboratorySupervisor

Name:

Name:

Signature:

Signature:

Date:

Date: