Facility Audit Checklist2

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FACULTY OF SCIENCE
FACILITY AUDIT CHECKLIST
Version 5.1: October 2014
Next Form Review: August 2017
Name of School:
Building No:
Room No:
Section/Area:
Purpose: (Teaching, Research,
Diagnostic, Commercial etc)
Use: (Laboratory/Prep Area etc)
Containment Level:
Facility Risk Rating:
Facility Manager:
Contact Details:
Date of Inspection:
Inspection Team Leader:
(Independent Staff Member)
Names of Inspection Team:
Signature of Inspection Team Leader:
Date:
Areas covered in the Facility Audit
Item No:
Category:
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
Policies and Documentation
Risk Management
Operational Facility Compliance/Fire Safety
General Building Condition, Housekeeping and Maintenance
Machinery and Equipment
Cold Storage
Biological Safety
Anatomy Facilities
Chemicals
Drugs and Scheduled Substances
Environmental
Other (list items)
Facility Inspection Audit Checklist
Page No:
2
3
4
5
6
7
8
9
10-11
12
13
13
Page 1 of 14
Version 5.1 – October 2014
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Hardcopies of this document are considered uncontrolled, please refer to the Technical Services Website for the latest version.
1. Policies and Documentation
Component
1A
Facility security & access
1B
Facility (Laboratory) Manual
1C
Facility Risk Register
1D
1E
Asset Register
Laboratory Awareness Guide
1F
Visitors Policy
1G
Prac Requirements Teaching
1H
Projects - Research
1I
Induction
1J
Workplace inspections
1K
Training Records
1L
Safe work procedures (SWP)
and/or Standard operating
procedures (SOP)
Risk assessments
1M
1N
Purchase of equipment and
chemicals procedure
1O
Accident / incident reports
1P
Staff Immunisation
Facility Inspection Audit Checklist
Compliance

X
N/A
Additional Notes /
Description
Limited to laboratory
personnel & others specified
by laboratory management
Faculty authorised access
only sign displayed on all
entrances
Faculty Format
Up to date
All risks documented on a risk
register
Up to date
Staff aware of and able
to access the guide
Register of all visitors
Complete list of all
requirements for practical
classes - provided a minimum
of 6 weeks in advance
Register of all projects being
undertaken in the facility
All personnel inducted into
the work area
Up to date list of personnel
inducted into the facility
Regular inspections by
compliance committees
IBC, RSC, CSC, ACEC, HE,
OH&S
(Please circle the relevant
inspections undertaken)
Dates of last inspection
All online training (ELMO)
completed by individuals and
documented
All staff made aware of their
training requirements and
maintain their own training
register
Documented for all
procedures and equipment
Documented for all
Class Practicals (Teaching)
Available for all Project
Activities (Research)
Documented for all
Diagnostic/Clinic activities
Risk assessments linked to
SWP’s and/or SOPs
All staff aware of the
University ‘s and Faculty’s
requirements for the
purchase of chemicals and
equipment
All staff are aware of the
reporting process in place
and that all accidents and
incidents must be reported
Staff are aware of any
discipline/activity specific
vaccinations, and that they
are required to maintain their
own vaccination records
Page 2 of 14
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2. Risk Management
Component
2A
Emergency evacuation
procedures & checklist
Compliance

X
N/A
Additional Notes /
Description
Procedures in place and
posted in a prominent
position
Emergency site plan
displayed
2B
Emergency contacts
Up to date list prominently
displayed
Allocated
Trained
At least one evacuation
performed annually and
documented
Qualified first aid officer
allocated to site
Installed
Up to Date
Complies with the standard,
flow tested annually and
documented
Activated regularly and
documented
Appropriate signage visible
Plumbed to potable water
and appropriate signage
displayed
Complies with the standard,
flow tested annually and
documented
Activated regularly and
documented
Appropriate signage visible
Plumbed to potable water
and appropriate signage
displayed
Testing & tagging of all
electrical equipment in
accordance with DFM policy
or covered by a risk
assessment
In good condition
2C
Building wardens
2D
Evacuation drill
2E
First aid
2F
First aid kit
2G
Emergency showers
2H
Eye wash stations
2I
In-service safety inspection
2J
Extension leads
2K
Power boards
Excessive use prohibited
2L
Double adapters
Use prohibited
2M
Personal Protective
Equipment (PPE)
Available and used:
Present no trip hazard
Lab Coats/Gowns
Enclosed footwear
Safety Glasses
Face Shields
Gloves
Respirators
PPE stored correctly
2N
Exiting the facility
Facility Inspection Audit Checklist
Removal of gloves & gowns
Signage – Wash hands
before exiting
Page 3 of 14
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3. Operational Facility Compliance/Fire Safety
Component
3A
Emergency Management
3B
Emergency isolation
switches
3C
Service isolation points
3D
Residual current device
3E
Fire extinguishers
3F
Fire blankets
3G
Emergency lighting
3H
Fire alarms
3I
Smoke / heat detectors
3J
Exit signs
3K
Designated fire doors
3L
General building condition
3M
Water supply
3N
Power points
3O
Chemical Pits
3P
Gantry/Overhead Crane
Facility Inspection Audit Checklist
Compliance

X
N/A
Additional Notes /
Description
Manifest Storage Box provided
on campus storage of chemical
manifests
Up to date chemical manifests
stored in the manifest storage
box
Electricity
Gas
Identified and detailed on the
site emergency plan
Location known:
Electricity
Gas
Water
Detailed on site emergency
plan
Staff aware if RCD’s have been
installed in the facility’s
distribution boards
Co2
Co2 Extinguisher located within
2 to 20m of the switchboard
ABE/BE powder (near
flammables cabinets)
Identified (signage)
Maintained
Installed
Identified (signage)
Installed
Operating
Tested regularly
Installed
Operating
Tested regularly
Installed
Operating
Tested regularly
Clear of all obstructions and
equipment
Operating
Clearly visible
Unobstructed
Identified (signage)
Gutters, drains unblocked
Windows cleaned
Screens on opening windows
Potable hot & cold water (AS
3500) provided near the exit
Back flow prevention in
accordance with AS 3500
installed
Adequate number available
In good condition
Circuit numbering on all
Maintained Records kept
maintained by DFM
Annual compliance tested by
an accredited authority
Documented in maintenance
logs
Page 4 of 14
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4. General Building Condition, Housekeeping and Maintenance
Component
4A
Compliance
Bench tops
Undamaged
Sinks
In good condition
Taps and Plumbing
No leaks
Electrical connections
In working order
Walls
Undamaged
Floors
Non-slip finish

X
N/A
Additional Notes /
Description
Clean
Undamaged
Free of trip hazards
Ceilings
4B
Furniture
4C
4D
Noise
Ventilation & air flow
Undamaged
No signs of water leaks
Ergonomic & easily cleaned –
no fabric covers
Levels acceptable
Air flow adequate
Air filters, vents clean and
free of dust
Adequate
4E
Lighting
4F
Pest control program
4G
Computers
4H
Bins
4I
Open spaces
4J
Shelving
4K
Walkways & aisles
Free from obstruction
All working
In place and documented
Keyboard covers in place in
lab areas
Labelled according to use
e.g. general waste, clinical,
glass
Under benches, cabinets &
equipment accessible for
cleaning
Stable
Not overloaded
4L
Exits
Free from obstruction
4M
Gown hooks
Adequate number supplied
4N
Facility maintenance
4O
Maintenance logs
4P
Cleaning
Facility Inspection Audit Checklist
Location appropriate for area
Decontamination of surfaces
and equipment prior to
maintenance
Maintenance & service
personnel advised of special
hazards
Signed clearance and
induction forms available
Maintenance for all areas
recorded
Maintenance for all
equipment recorded
BEIMS requests documented
Cleaning schedule for all
areas in place and
documented
Cleaning schedule for all
equipment in place and
documented
Page 5 of 14
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5. Machinery and Equipment
Component
5A
Machinery and Specialist
Equipment
5B
Emergency stop switches
5C
Obstruction
5D
Guards
5E
Electrical & Hoses
5F
Pressure steam steriliser
(autoclave)
Compliance

X
N/A
Additional Notes /
Description
Operating instructions
(SWP’s/SOPs) available
Safety signs adequate and
clearly visible
Training provided, records
available
Clearly labelled
Switches easily accessible
Machines & equipment free
from obstruction
All moving parts adequately
guarded where required
Connections in good order
Easily accessible
Compliance tested annually
Copy of calibration report
located near appliance
5G
Pressure vessels
(compressors)
5H
Fume Cabinets
Boiler inspected every two
years by accredited authority
where applicable
Copy of boiler inspection
certificate located near
appliance
Operating instructions
(SWP/SOP) available
Safety signage adequate and
clearly visible
Inspected
Maintained (documentation)
Annual Performance testing
undertaken by accredited
testing authority
All documented in the
Maintenance Logs
CO2 fire extinguisher located
nearby but not less than 1M
from the cupboard
Signage no more than 2.5L of
flammable liquid in fume
cupboard
Storage of chemicals in fume
cupboards prohibited
5I
5J
Laminar Flows
Biohazard Safety Cabinet
Facility Inspection Audit Checklist
Annual Performance testing
by accredited testing
authority
All documented in the
Maintenance Logs
Annual Performance testing
by accredited testing
authority
All documented in the
Maintenance Logs
Page 6 of 14
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6. Cold Storage
Component
6A
Refrigerators, Freezers –
General (domestic,
commercial)
Compliance

X
N/A
Additional Notes /
Description
Full Manifest of contents
including values in place and
up to date.
Items not stored in food
containers
No food or drink signs
No Flammables signs
Biological Hazard signs
DG Class signs
6B
Refrigerators, Freezers Specialist , (Spark Free, -80,
Ultra Low)
Radiation signs
Temperatures monitored and
logged or external
temperature monitoring in
place
Full Manifest of contents
including values in place and
up to date
Items not stored in food
containers
Contents appropriate for
specialist use
Contents stored correctly for
specialist use
No food or drink signs
Biological Hazard signs
DG Class signs
Maintenance program in
place and documented
Temperatures monitored and
logged or external
temperature monitoring in
place
6C
Cold rooms/Freezer rooms
SWP in place
Full Manifest of contents
including values in place and
up to date
Items not stored in food
containers
No food or drink signs
No Flammables signs
Biological Hazard signs
DG Class signs
Temperatures monitored and
logged or external
temperature monitoring in
place
Facility Inspection Audit Checklist
Page 7 of 14
Version 5.1 – October 2014
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7. Biological Safety
Component
7A
Facility security & access
and Signage
7B
Ventilation & air flow
7C
7D
7E
Compliance
Register of all organisms
SDS or Specifications Sheet
for Organisms
SDS’s or specifications sheet
available where applicable
All cultures clearly labelled in
accordance with regulations
Are all spore dispersing
organisms sealed during
storage
Procedures producing
aerosol production carried
out in a biological safety
cabinet or other equipment
designed to contain aerosols
7F
Specialist Storage
Requirements
7G
Aerosol production
7H
Infectious material
containers
X
N/A
Additional Notes /
Description
All necessary signage in
place for PC2 and OGTR
facility in accordance with
regulations
Lab doors closed when work
is in progress
Recirculation permitted but
not to outside PC2 facility
Register
Cultures

Clearly labelled
Stored appropriately
7I
Disposal of infectious waste
7J
7K
Decontamination of work
surfaces
Sharps
7L
Spills
7M
Spills Kit
In accordance with
documented procedures
Use of appropriate chemical
solution
Sharps procedures adopted
& adhered to
Procedures in place
Available
Staff trained in its use.
7N
Writing areas
7O
Labels
7P
Food Products
7Q
Wash basins
Facility Inspection Audit Checklist
Provision of separate area for
writing materials (PC2 only)
Use self adhesive labels only
Used in Laboratories labelled
not for human consumption
Taps hands free (where
required)
Page 8 of 14
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8. Anatomy Facilities
8A
Registers
8B
Cleaning and
Decontamination Schedules
8C
Safe Work Procedures
Detailed register of all
cadaveric specimens
currently in the facility
including locations
Detailed register for all
monitoring and treatment of
specimens in the facility
A register of contamination
events and treatment
outcomes for the facility
Schedules in place which
outline the daily, weekly,
monthly and annual cleaning
and decontamination
activities for the facility
Documented SWP’s/SOP’s
in place for:
Containment of cadaveric
material
Storage and movement of
cadaveric material within a
facility
Movement of cadaveric
material from the facility
Vat preparation, maintenance
and drainage
Dissections
Spills
8D
Record Keeping
8E
Formaldehyde
Facility Inspection Audit Checklist
Daily shut down procedures
Detailed records maintained
for student inductions and
student use of cadaveric
material
Exposure monitoring in place
and recorded
Page 9 of 14
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9. Chemicals
Component
9A
Inventory/Manifest Chemicals
Compliance

X
Additional Notes /
Description
N/A
Hard copy Inventory available for
all chemicals stored in facility
which clearly identifies all
hazardous chemicals.
Inventory entered on ChemFFX
9B
Chemical Risk
Assessment
9C
SDS
9D
Labelling
Chemical Risk Assessment
completed prior to purchase of
all hazardous chemicals and
dangerous goods
Available for all hazardous
chemicals used & stored in the
facility
Current (in date) manufacturer’s
SDS available for all hazardous
chemicals
All chemical containers clearly
labelled & complying with
Hazardous Chemicals
Regulation
9E
Storage

Teaching
x
n/a

Research
x
n/a
Chemicals stored in compatible
containers in accordance with
the standard AS 2243.10
Chemicals not stored above a
height of 1.5m (including when
stored above a bench)
Chemicals not stored in food
containers
No excessive amounts of
solvents stored
Dangerous Goods Storage
Cabinets in place where required
Dangerous Goods Storage
Cabinets signed and not
overloaded
Dangerous Goods Storage
Cabinets in good condition - no
corrosion, doors close correctly
Procedure in place for decanting,
transferring and transporting
chemicals
9F
Handling
9G
Chemical compatibility
Compatibility of chemicals
checked prior to storage
9H
Protective equipment
Appropriate PPE worn when
handling chemicals
9I
Toxic chemicals and
carcinogens
Procedures in place for handling
special chemicals
9J
Waste
All chemical waste disposed of
as per Statutory Requirements
9K
Spill Kits
Available
Staff trained in their use
Facility Inspection Audit Checklist
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L
Chemical spill
9M
Safety carriers
Used for carrying chemicals in
glass / plastic containers of 2L or
more
9N
Gas Cylinders
Restrained (using chain and/or
bracket) –rope not acceptable
Emergency procedure in place
Secure/cage locked (outside)
Stored/segregated correctly
Signage
9O
Liquid Nitrogen Storage
Correct PPE available
Used In accordance with
documented procedures
Container size appropriate for
the size of the room
Volume of air displaced
Facility Inspection Audit Checklist
Page 11 of 14
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10. Drugs and Scheduled Substances
Component
10A
Inventory/Manifest –
Scheduled Drugs
General Requirements
10B
Schedule 4 Drugs
10C
Schedule 4D Drugs –
(Sodium Pentobarbital)
10D
Schedule 8 Drugs – Drugs
of Addiction
Compliance

X
N/A
Additional Notes /
Description
Hard copy Inventory for all
Scheduled Drugs stored in the
facility.
Drug Inventory entered on
relevant record keeping
software eg. ChemFFX, Clinic
operational software
Scheduled 4 drugs stored
away from general use areas
and in lockage storage units
Records of usage maintained
Scheduled 4D Drugs not stored
with Scheduled 4 Drugs
Stored in a locked cupboard
away from public access
Detailed records of purchase,
usage and disposal maintained
Staff aware of the purchase,
use and reporting requirements
of possessing Schedule 8
Drugs – Drugs of Addiction.
Authorisation from the PSB
required
Stored in a Drug Safe with
restricted access
10E
Regulations
10F
Faculty Procedures
Facility Inspection Audit Checklist
Scheduled 8 Drugs stored
separately to other scheduled
substances (except S4D)
Accurate registers of use
maintained and stored with
Schedule 8 Drugs
Staff are aware that the use of
out of date drugs is prohibited
Staff are aware that it is illegal
to be gifted out of date drugs
Staff are aware that the use of
real medication is not permitted
in the areas where simulated
medications can be substituted
such as nursing and paramedic
Simulated medication used in
an area must be labelled with
the appropriate wording to
indicate it is for simulation
purposes only
Page 12 of 14
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11. Environmental
Component
11A
Waste management
11B
Documented procedures
11C
Storage of waste
11D
Disposal of waste
Compliance

X
N/A
Additional Notes /
Description

X
N/A
Additional Notes /
Description
Types of waste generated in
the facility identified and
documented
SWP’s/SOPs in place for
processing the various waste
streams relevant to the
facility
Waste segregated in
accordance with documented
procedures
List of waste storage areas
List of waste pick up sites
12. Other (list items)
Component
Facility Inspection Audit Checklist
Compliance
Page 13 of 14
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Reference Documents
Australian Standards
Available online, access available through the Technical Services Website
AS 1319 Safety signs for the occupational environment
AS/NZS 2243.1 Safety in laboratories - General
AS/NZS 2243.2 Safety in laboratories - Chemical aspects
AS/NZS 2243.3 Safety in laboratories – Microbiological safety and containment
AS/NZS 2243.6 Safety in laboratories – Mechanical aspects
AS 2243.7 Safety in laboratories – Electrical aspects
AS/NZS 2243.8 Safety in laboratories – Fume cupboards
AS/NZS 2243.10 Safety in laboratories – Storage of chemicals
AS/NZS 2647 Biological safety cabinets – Installation and use
AS/NZS 3838 The storage and handling of mixed classes of dangerous goods in packages and intermediate
bulk containers.
AS/NZS 2982 Laboratory design and construction
AS 1940 The storage and handling of flammable and combustible liquids
AS 3780 The storage and handling of corrosive substances
AS 4452 The storage and handling of toxic substances
AS 4332 The storage and handling of gases in cylinders
AS 4267 Pressure regulators for use with industrial gas cylinders
AS/ NZS 3816 Management of clinical and related wastes
Facility Inspection Audit Checklist
Page 14 of 14
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