Laboratory Close Out Policy

Policy

Closeout or transfer of responsibility of laboratories that possess biological, chemical, or radiological materials must be conducted in a manner that ensures that all such materials are identified and labeled and, at the proper time, transferred to another responsible party or properly disposed of.

Responsible Authority

Vice President for Research; Environmental Health and Safety Department

Scope

This policy applies to all laboratories, stockrooms, and storerooms maintained by the University of Nevada, Reno that possess biological, chemical, or radiological materials.

Background

It is preferred that all laboratory assets be reassigned to faculty who will use the materials, products and devices for ongoing useful purposes. Chemical, biological, and radiological materials, however, are frequently left behind when laboratory researchers end their association with the university, or otherwise closeout or transfer responsibility of a laboratory. These orphaned materials are often improperly labeled and inappropriately packaged. In some instances these materials are completely unlabeled, effectively qualifying them as unknown hazardous materials. These materials represent increased health and safety risks to personnel, as well as financial risks due to characterization and disposal costs, and regulatory fines. Additional costs may include hazardous material response, facility repair, and equipment replacement resulting from fire or spills of these orphaned materials.

Reference Regulations

  • 29 CFR 1910.1450, “Occupational Exposure to Hazardous Chemicals in Laboratories”
  • 42 CFR 73, “Possession, Use, and Transfer of Select Agents and Toxins”
  • 7 CFR 331; 9 CFR 121, “Agricultural Bioterrorism Protection Act of 2002; Possession, Use, and Transfer of Biological Agents and Toxins”
  • NAC 459, “Hazardous Materials”
  • National Institutes of Health, “NIH Guidelines for Research Involving Recombinant DNA Molecules” (latest edition)
  • Centers for Disease Control and Prevention/National Institutes of Health, “Biosafety in Microbiological and Biomedical Laboratories” (latest edition)

Definitions

Laboratory

The physical space for which a PI is responsible and uses for the purpose of conducting laboratory work. For purposes of laboratory closeout or transfer of responsibility, instrumentation, hazardous materials, and equipment for which the PI is responsible or that may be contained in laboratory space for which the PI is responsible or shares responsibility, are subject to this policy no matter where the space is located. Responsibility can be gained through formal assignment; informal acceptance of responsibility through primary use, maintenance, or repair; or acquisition by purchase or other means.

Closeout and/or Transfer of Responsibility for Laboratories

The discontinuance of all laboratory operations for which a specific PI is responsible, accompanied by written acknowledgement by the PI. Such acknowledgement indicates that the PI, and any personnel working under his or her supervision, will vacate the laboratory space as specified by the PI. The PI need not end their association with the University, or physically leave the University, for a laboratory closeout or transfer of responsibility of the laboratory to occur.

Responsibilities

Deans, Department Chairs, and Directors

Ensure that all faculty and principal investigators are aware of the responsibilities and procedures contained in this policy.

Provide administrative enforcement of this policy with regard to the closeout or transfer of responsibility of laboratories under their administrative responsibility.

Ensure that any PI who is closing out or transferring responsibility of their laboratory is informed of this policy and is provided with the “Laboratory Closeout/Transfer Notification Form” (Appendix I) and the “Laboratory Closeout/Transfer Checklist” (Appendix II).

Ensure that a copy of the completed and signed Laboratory Closeout/Transfer Checklist is provided to the new occupant of laboratory space prior to their occupancy.

Academic Departments and Other Administrative Units

The PI’s home academic department or other administrative unit is responsible for costs arising from noncompliance with this policy when the PI has physically left the University or does not have sufficient operating funds to cover such costs. Examples of these costs include analysis of unknown or incompletely characterized hazardous materials; disposal of hazardous materials requiring special handling or treatment (for example, shock sensitive chemicals and mixed waste); and regulatory fines or other regulatory penalties associated with improper handling, or disposal of hazardous materials and wastes.

Principal Investigator/Laboratory Supervisor

When a laboratory ceases operations for any reason or responsibility for the laboratory is transferred to another PI, ensure that the laboratory is closed out or transferred in accordance with this policy. Each PI is responsible for all instrumentation, hazardous materials, and equipment that is contained in any laboratory space for which they are responsible or share responsibility, no matter where the space is located.

Ensure that materials transferred to another laboratory (on campus or off campus) are packaged, labeled, and shipped in accordance with local, state, and federal regulations covering the specific hazardous materials to be transferred.

When a laboratory closeout or transfer is not conducted according to this policy, the PI is responsible for the financial costs arising from the noncompliance through the use of operating funds under their purview. Examples of such costs include analysis of unknown or incompletely characterized hazardous materials; disposal of hazardous materials requiring special treatment or handling (for example, shock sensitive chemicals and mixed waste); and any regulatory fines or other regulatory financial penalties associated with improper labeling, handling, or disposal of hazardous materials and wastes.

Environmental Health and Safety Department

When written notification of a laboratory closeout or transfer is received (via the Laboratory Closeout/Transfer Form), EH&S will schedule a meeting with the PI (or designated alternate) currently responsible for the laboratory to evaluate specific requirements that must be completed prior to the closeout or transfer. Based on this evaluation, EH&S will provide a written summary to the responsible PI within 15 days after the evaluation.

Provide chemical waste containers, and sharps containers and autoclavable waste bags for biohazardous waste (all limited to standard EH&S-supplied containers and bags).

Provide guidance on characterization, handling, treatment, and disposal of biological, chemical, and radiological waste. Collect, transport, store, and coordinate final disposal of biohazardous sharps waste, and chemical and radiological waste. With regard to hazardous materials requiring special handling, treatment, or disposal (for example, shock sensitive compounds), EH&S provides technical guidance and assistance in coordinating removal and disposal by a third party (as required). Financial costs associated with handling and disposal of these materials are considered “exceptional expenses” and are the responsibility of the PI, with the academic department or administrative unit being secondarily responsible.

Provide guidance and assistance on packaging and labeling of hazardous materials for transfer or shipment.

Procedures

  1. All laboratory PIs who are closing out or transferring responsibility of their laboratories must submit Laboratory Closeout/Transfer Notification Forms (Appendix I) to EH&S at least 30 days prior to scheduled closeout or transfer date. This advance notice is needed for laboratory clean out, transfer or disposal of hazardous materials, and to ensure compliance with regulatory requirements. Upon receipt of a notification form, EH&S will schedule a meeting with the PI (or designated alternate) to evaluate specific requirements that must be completed prior to the closeout or transfer EH&S will provide the PI with a written summary of the requirements within 15 days after the evaluation.
  2. The PI must also complete the Laboratory Closeout/Transfer Checklist (Appendix II), and submit it to their department (with a copy to EH&S). The PI will be considered responsible for the laboratory space until all action items on the Checklist have been completed, and the Checklist has been signed by all parties and submitted to the PI’s home department, with a copy of the Checklist sent to EH&S. The academic department must provide a copy of the completed and signed checklist to the new occupant prior to their occupancy of the laboratory. When responsibility for a laboratory is transferred from one PI to another, the receiving PI must sign the Checklist indicating that they have accepted responsibility for the laboratory in its current condition.
  3. Prior to any PI closing out or transferring his or her laboratory, all biological, chemical, and radiological materials that will remain at the University must be transferred to another University PI or Department (by mutual agreement). Radiological materials can only be transferred to a user who is currently authorized to maintain and use the specific material. All transfers of radiological materials must be coordinated by the University Radiation Safety Officer (RSO). Chemical containers transferred to another University PI require that the University chemical inventory be updated to reflect the relocation. The PI will need to consult with EH&S as to the most efficient method to update the inventory database. Biological materials can be transferred to another PI who is authorized for the agent(s) by a currently approved Memorandum of Understanding and Agreement (MOUA).
    These materials must be in appropriate containers and be properly labeled. Chemicals must be labeled with the chemical name, hazard information, and date the material was received or last used (if known). Peroxide-forming chemicals must be tested for peroxide levels, with the test date and results listed on the chemical container. Radioactive materials must be labeled with the identity of the radioisotope, activity, and date, and be packaged in leak-proof secondary containers. Biological materials must be labeled with the name of the biological agent, and hazard information (including biosafety or risk level). Biological materials must be packaged in leak proof secondary containers, as appropriate for the biosafety level.
    EH&S personnel will assist in the safe transport of biological, chemical, and radiological materials on the university campus.
  4. Transport of all radioactive materials that are going with the PI must be coordinated through the RSO. This will ensure that the university’s radioactive material inventories are current, and that materials are properly packaged and shipped.
  5. Off-site shipment of biological materials and chemicals is the responsibility of the PI. EH&S will provide consultation on proper packaging and labeling of these materials and inspect materials prior to shipment. It is the responsibility of the PI to ensure that these materials are shipped only to an authorized institution in accordance with state and federal regulations.
  6. All laboratory equipment and labware, regardless of whether it is to be transferred to another institution or stay at the University, must be cleaned and decontaminated. Radiological decontamination must be verified by the RSO. This will protect new lab occupants from the unnecessary risk, expense, and inconvenience presented by contaminated materials.
  7. All radiation monitoring badges (personnel dosimeters) must be returned to the RSO prior to the PI’s exit, as well as any radiation detection or shielding devices that may have been borrowed in support of special projects.

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