University of Missouri-Kansas City
Environmental Health and Safety Department
4747 Troost Ave., Suite 3
Ph. 235-5241
FAX 235-6559
SAFETY QUESTIONNAIRE
Principal Investigator:
Phone:
Laboratory Number:
Building:
Department:
Y
N
Please check “YES,” or “NO” for each item.
1. What Hazards are located or used in Laboratory?
a. Hazardous Chemicals?
b. Biological Material (ie., virus, rDNA, Select Agents, …)?
c. Radioactive Material (ie., sources, isotopes, radiation emitting devices,…)?
d. Laboratory Animals?
e. Laser(s) or Magnetic Field Generator?
Y
N N
A
Please check “YES,” “NO,” or “NOT APPLICABLE” for each item. Comments may be written next to the
question or at the end of the survey.
A. Written Laboratory Safety Plan
1. Do you have written procedures for:
a. First aid emergency response?
b. Hazardous waste management?
c. Chemical spills?
d. Biohazard spills?
e. Radioactive material spills?
f. Loss of electricity; Fire; Severe weather; Earthquake; etc.?
g. Planned shutdown of gas, water, or electricity?
2. Are records kept of safety inspection results and corrective actions?
B. Safety Training
1. Do laboratory personnel receive training in the following subjects:
a. Chemical safety including the proper selection, use, and maintenance of
personal protective equipment?
b. Hazardous Waste disposal?
c. Fire extinguisher training?
d. Location and use of safety/deluge showers and eyewashes?
1
EHS 2008
e. Chemical spills clean up?
f. Bloodborne pathogen exposure control?
g. Shipping/transporting hazardous materials?
h. Safe work practices using biological safety cabinets?
i. Safe work practices using fume hoods?
2. Does the research supervisor or department keep training records on all
laboratory personnel and visitors?
C. General Emergency Preparedness
1. Are the following posted:
a. Emergency phone numbers?
b. Emergency response instructions?
c. Biological warning placards
d. Radiation warning placards
D. Laboratory Conditions
1. Accessibility:
a. Are pathways clear to eyewashes and safety showers?
b. Is there easy access to electrical panels?
c. Is there easy access to fire extinguisher?
d. Is a first-aid kit available and stocked with non-expired materials?
E. Hazardous Material Safety
1. Is a current inventory of hazardous materials available?
2. Do employees have access to Material Safety Data Sheets (MSDS)?
3. Are all containers labeled appropriately?
4. Are incompatible hazardous materials isolated from each other?
5. Are refrigerators containing hazardous materials placarded to identify contents
and restrictions (e.g., “NO FOOD”)?
6. If a refrigerator is used to store flammable materials, is it explosion-proof and
labeled as explosion proof?
7. If ten (10) gallons or more of flammable liquids are in a room:
a. Are the flammable liquids stored in a cabinet designed for storing
flammables?
b. Are flammable liquids stored away from open flames or sparks?
8. Are ethers and peroxide-forming compounds (e.g., aldehydes, ethers, benzylic
hydrogen compounds, allylic compounds, vinyl compounds) labeled with dated
when received and when opened?
2
EHS 2008
9. If compressed gas cylinders are located in the lab:
a. Are the cylinders secured with chains/straps?
b. Are all gas cylinders inventoried?
c. Are the cylinders stored away from heat sources?
F. Biological Safety
1. Are biological safety inspections performed periodically?
2. If the laboratory's activities involve recombinant DNA, does it have a current
protocol authorization from the IBC? If so, indicate BSL _________
3. Has the biosafety cabinet been certified within the last year?
4. Are sharps placed in sharps containers at point of generation?
5. Are biohazardous liquid wastes decontaminated by autoclaving, bleaching, or
other methods before disposal via the sewer?
6. Are biohazardous solid wastes autoclaved before disposal?
G. Radiation Safety
1. Are radiation safety inspections performed periodically?
H. Hazardous Chemical Wastes
1. Are employees familiar with the procedure for requesting waste pickup by EHS?
2. Are empty containers triple rinsed and the rinseate saved prior to discard?
3. Are hazardous chemicals neutralized according to “Approved Treatment
Protocols” in order to reduce hazardous wastes quantity or hazard?
Comments:
PI Name: (Print)
PI Signature:
Date:
To request a Certificate of Environmental Compliance complete this form in full with authorized signature. Mail or fax a
copy to the Director of the Department of Environmental Health and Safety.
3
EHS 2008