University of Texas Health Science Center at San Antonio
Environmental Health & Safety Department
Chemical Safety Division
Laboratory Safety Evaluation Record
BUILDING
ROOM / AREA
_COR
Page 1 of 3
E,H&S PERSONNEL CONDUCTING EVALUATION ___________________________
,
DATE OF EVALUATION___
PRINCIPAL INVESTIGATOR / SUPERVISOR / MANAGER____________
TITLE_____
DEPARTMENT___________
CONTACT PERSON__________________________________________
TITLE_____
CONTACT PHONE_______
STREET ADDRESS______________________
/
/
,
-
,
1) ROOM TYPE as listed in EHS:
RES-Research Lab
AUT-Autoclav/Wsh
TCL-Tiss. Cult. Lab
CEP-Energy plant
CLL-Clinical Lab
CHA-Utility chase
ANA-Anatomy Lab
CLA-Class rm (<50)
ANI-Anml holding
DRK-Dark Room
ANL-Anml Res. Lab
EQU-Equip. room
CITY____
INA-Inactive lab/rm
LEC-Lecture hall
MDL-Muli disc. lab
MEC-Mechanical
OFC-Office area
OTH-Other room
ZIP + 4_________
-
PET-PET scanner
PHY-Phy. Plt. shop
PRL-Prosthetic lab
PRO-Procedure rm
RIC-Res. Imag. Ctr
STO-Storage room
2) Biological agents used?
NO
SELECT AGENTS IN USE?
YES, LIST AGENTS:
,
,
3) Chemical hazards present?
NO
YES, Check or LIST TYPES:
Corrosive,
Flammable,
Peroxide former
Carcinogens – list:
,
,
,
,
,
Other – list:
NFPA: Health=
, Fire=
, React.=
, Spc.=
Haz. Waste Satellite Collection - YES, list waste
4) Radioactive materials used?
NO
YES, LIST ISOTOPES:
5) Are any LASERS in use?
NO
YES, LIST TYPE:
6) Are special hazards present?
NO
YES, LIST TYPE:
7)
PERSONNEL
,
,
FIRST
NAME
MI
HSC
BADGE #
XXXXXXXXXXX
XXXXXXX
X
XXXXXXXXX
,
,
,
TRAINING:
UV,
YES
BSL: 1,
,
YES
High voltage,
&
LAST NAME
NO
TEA-Teaching lab
WHS-Warehouse
WIC-Walkin cb or fr
WNC-Walkin incub.
2,
X-Ray:
NO
3,
4
YES
NO
N/A
Other – list:
TRAINING:
NEO
Safety
Aware.
SPECIFIC
CHEMICAL
HAZARD
Y
Y N
N
LAB SAFETY
& Haz. Waste
Generator’s
N/A Y
N
BASIC
BIO & BBP /
BBP Trng.
N/A Y
BASIC RAD Safety
Orient or:
N N/A Y
N
RAD20
N/A
√
Revision 01/05/2005
University of Texas Health Science Center at San Antonio
Environmental Health & Safety Department
Chemical Safety Division
Laboratory Safety Evaluation Record
Date Performed: _____________
Procedure:
Lab / Room:
__________________
P.I. / Supervisor: _________________
Evaluate each of the following laboratory items according to the requirements of the appropriate
UTHSCSA Safety Handbook(s). Place a check in the appropriate space for Y (Yes), N (No), N/O (Not
Observed), or N/A (Not Applicable). Enter comments in the space provided.
Y
GENERAL
POSTINGS
GENERAL
SAFETY
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
GENERAL IAQ
FIRE SAFETY
PHYSICAL
SAFETY
Page 2 of 3
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
25.
26.
27.
28.
29.
30.
31.
32.
33.
34.
35.
36.
37.
N
N/O
N/A
COMMENTS?
NFPA 704 Code
No Food or Drink
Radiation
Biohazard (Entry/Exit Procedures Posted?)
UV Light
LASER
Current emergency phone numbers posted?
TDH Hazard Communic. Notice to Employees
TDH Radiation Notice to Employees
Current Chemical Safety Handbook available?
Current Biological Safety Handbook available?
Current Radiation Safety Handbook available?
Current Physical Safety Standards Handbook
available?
Current Emergency Evacuation & Response
Plan available?
Appropriate training records on file?
General housekeeping orderly?
No food or drink observed in lab?
No unusual odors present?
Is room pressure negative to corridor?
No visible particulates coming from vents?
Fire egress unobstructed?
Access to pull alarms & fire equipment clear?
Fire extinguisher available & inspected?
Smoke detector present?
Self-closing door to lab functional?
Path to electric panel & gas shut off clear?
Natural gas lines functional, labeled, & used
properly?
Heat sources separated from combustibles?
18 inches clearance to sprinklers?
18 inches clearance to lights & air vent ducts?
Absence of slip, trip, & cut hazards?
Compressed gas cylinders secured?
Noise levels acceptable (action level = 85 dB)?
Guards in place for mechanical hazards?
Electrical equipment grounded properly?
Extension cords not in use (except
emergency)?
Circuits / outlets not overloaded?
Revision 01/05/2005
University of Texas Health Science Center at San Antonio
Environmental Health & Safety Department
Chemical Safety Division
Laboratory Safety Evaluation Record
Y
BIOLOGICAL
SAFETY
38.
39.
40.
41.
42.
43.
44.
45.
46.
CHEMICAL
SAFETY
47.
48.
49.
50.
51.
52.
53.
54.
55.
56.
57.
58.
59.
60.
61.
62.
63.
64.
N
N/O
Page 3 of 3
N/A
COMMENTS?
Standard / Universal precautions utilized?
Potentially exposed workers offered vaccines /
medical surveillance?
Vaccination records available?
PPE available and used as required?
Hand washing facilities adequate?
Refrigerators, freezers, instrumentation posted
with biohazard label – no food or drink label as
appropriate?
Biological Safety Cabinet certified annually?
U V lamps used properly & posted?
Medical waste / sharps properly stored and
handled?
Hazardous chemical list / inventory updated?
CSC approval to work with carcinogens on file?
Required (OSHA) chemical monitoring on file?
Appropriate warning signs posted (hood,
refrigerators, etc.)?
Controlled substances secured?
Excessive chemicals not stored in fume hood?
Linear flow rate in fume hood adequate (80 –
120, avg. 100 lfpm) and tested annually?
Chemicals stored and segregated properly?
Secondary containers labeled properly (hazards
& date received)?
No very old or potentially explosive chemicals?
No flammables stored in non-explosion proof
refrigerator?
Hazardous liquid chemicals stored below
employee ‘s eye level or 6 feet?
Safety shower / eyewash available within 100 ft.
or 10 seconds travel?
Employees able to locate MSDS & Safety
Handbook(s)?
Chemical waste properly stored? Liquid waste
capped / closed?
Chemical waste properly labeled including
approximate component %?
Previous deficiencies adequately resolved?
There are no additional safety concerns?
Any unsatisfactory safety condition or concern must be relayed to the appropriate UTHSCSA constituent utilizing the
Chemical Safety Division - Laboratory Evaluation Deficiency Report.
Date Performed: ___________
Report Date:
___________
SIGNATURES
This facility has been evaluated against criteria specified in the UTHSCSA Chemical, Biological, Radiation, and Physical
Standards Safety Handbooks.
Evaluated By: _________________________________
Date evaluated: ________________________________
Reviewed By: _________________________________
Date reviewed: ________________________________
Revision 01/05/2005