CHEMICAL HYGIENE PLAN
Occupational Safety and Health Standards
Title 29 Code of Federal Regulations 1910.1200, 1910.1450
________________________
VP
________________________
Safety Officer
________________________
Facility Safety Manager
JANUARY 2015
TABLE OF CONTENTS
1.
PURPOSE
Page 1
2.
DEFINITIONS
Page 1
3.
SCOPE
Page 2
4.
GENERAL LAB SAFETY GUIDELINES
Page 2
5.
RESPONSIBILITIES
Page 4
6.
LABORATORY SPECIFIC CHEMICAL HYGIENE PLAN
Page 6
7.
CHEMICAL INVENTORY
Page 6
8.
MATERIAL SAFETY DATA SHEETS (MSDS) /SAFETY DATA
SHEETS (SDS)
Page 7
9.
CHEMICAL PROCUREMENT, MANAGEMENT, DISTRIBUTION
& STORAGE
Page 7
10. LABELING
Page 8
11. ENGINEERING CONTROLS
Page 9
12. PERSONAL PROTECTIVE EQUIPMENT
Page 9
13. WASTE REMOVAL/DISPOSAL
Page 10
14. SPILLS AND ACCIDENTS
Page 10
15. EMPLOYEE EXPOSURE ASSESSMENT AND MONITORING
Page 11
16. EMPLOYEE TRAINING
Page 12
17. ACCESSIBILITY
Page 13
18. LIST OF APPENDICES
Page 14
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1. PURPOSE:
The Chemical Hygiene Plan (CHP) was created in order to establish guidelines and work
practices at the Feinstein Institute which would satisfy the requirements set forth by the
Occupational Safety and Health Administration (OSHA) Laboratory Safety Standard: 29 CFR
1910.1450 and the revised Hazard Communication Standard (HCS) that conforms with the
United Nations Globally Harmonized System (GHS). The CHP outlines guidelines and work
practices capable of protecting employees from health hazard(s) potentially present during
the handling, use, and discarding of toxic and hazardous substances used in laboratories. It
is the basis for the chemical hygiene program to ensure the proper implementation of
controls to protect the safety and health of all Feinstein Institute workforce members. Critical
to the OSHA Laboratory Standard, employee exposure to laboratory chemicals must be kept
below permissible exposure limits as outlined by Table Z-1 of OSHA 29 CFR 1900.1000.
2. DEFINITIONS:
ACUTE: An adverse effect with symptoms of high severity coming quickly to a crisis.
CARCINOGEN: A substance capable of causing cancer.
CHEMICAL AGENTS: A wide variety of fluids that have a high potential for body entry by various
means. Some are more toxic than others and require special measures of control for safety and
environmental reasons.
CHRONIC: An adverse effect with symptoms that develop slowly over a long period of time or that
frequently recur.
COMBUSTIBLE: Able to catch on fire and burn.
DOT: Department of Transportation
EPA: Environmental Protection Agency
EXTREMELY HAZARDOUS SUBSTANCE: Select carcinogens, reproductive toxins, and substances
with a high degree of acute toxicity (Permissible Exposure Limit, PEL, or less than 2 ppm or 2mg/m 3)
FLAMMABLE: Capable of being easily ignited and of burning with extreme rapidity.
HAZARDOUS CHEMICAL: Chemical that is a physical and/or health hazard
INFECTIOUS AGENTS: Sources that cause infections either by inhalation, ingestion, or direct contact
with the host material.
LABORATORY SCALE: Work with chemicals that can easily and safely be manipulated by one
person excluding the commercial production of chemicals for sale.
LABORATORY USE: A workplace where relatively small quantities of hazardous chemicals are used
on a non-production basis.
LC 50: The concentration of a substance in air that causes death in 50% of the animals exposed by
inhalation. A measure of acute toxicity.
LD 50: The dose that causes death in 50% of the animals exposed by swallowing a substance. A
measure of acute toxicity.
MSDS/SDS: Material Safety Data Sheets / Safety Data Sheets
MUTAGEN: A substance that induces or increases genetic mutations by causing changes in DNA.
NEW PROCESSES OR EQUIPMENT: New equipment or procedure used at Feinstein that could
possibly expose employees to a hazardous material.
OSHA: Occupational Safety and Health Administration, the regulatory branch of the Department of
Labor concerned with employee safety and health.
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PEL - Permissible Exposure Limit: This is the legally allowed concentration in the workplace that is
considered a safe level of exposure for an 8-hour shift, 40 hours per week.
pH: A measure of how acidic or caustic a substance is on a scale of 1 to 14. A pH of 1 indicates that
a substance is acidic; a pH of 14 indicates that a substance is basic.
PHYSICAL AGENTS: Workplace sources recognized for their potential effects on the body. Heat
exposure or excessive noise levels are examples of this risk group.
PPE - Personal Protective Equipment: Equipment used to reduce employee exposure to hazards.
SDS – Safety Data Sheets: Formerly known as MSDS, now have a uniform 16 section format with
largely the same information as the MSDS.
SENSITIZERS: Agents to repeated exposure over time creating an allergic reaction at some point in
time.
STERILITY: Changes made in male or female reproductive systems resulting in inability to reproduce.
TERATOGEN: Substance that induces or increases the incidence of congenital anomaly in the
developing embryo.
TLV - Threshold Limit Value: The amount of exposure allowable for an employee in an 8-hour day.
3. SCOPE:
This policy applies to all members of The Feinstein Institute for Medical Research (“Feinstein”)
workforce including but not limited to employees, contractors, volunteers, students and other persons
performing work for or at the Feinstein.
4. GENERAL LABORATORY SAFETY GUIDELINES:
When working in the lab setting the following general guidelines must be followed:
1. All laboratory staff must know the location of their Material Safety Data Sheets (MSDS)/Safety
Data Sheets (SDS), standardized spill kits and Chemical Hygiene Plan.
2. Know how to use the standardized spill kit including proper clean up disposal procedures.
3. All chemicals must be stored by compatibility (e.g., acids separate from bases, oxidizers
separate from flammables, potassium cyanide separate from acid, heat and UV light, etc.).
4. Flammable materials not in use must be stored in a flammable storage cabinet with
containment. (Appendix A)
5. Flammable materials, which need to be refrigerated, must be store in flammable safe
refrigerators only.
6. Total quantities of flammable materials stored in a laboratory must not exceed the permitted
amounts. These quantities vary based on the construction of the laboratory. All corrosives
should be stored below eye level.
7. All chemical containers including squirt bottles must be clearly labeled (no abbreviations) with
their contents.
8. Do not use mouth suction for pipetting or starting a siphon.
9. Do not smell or taste chemicals. Apparatus that can discharge toxic chemicals (vacuum
pumps, distillation columns, etc.) should be vented into local exhaust devices.
10. All toxic or poisonous chemicals must be used in a hood. Do not allow the release of toxic
substances in cold rooms and warm rooms, since these contain re-circulated atmospheres.
11. No chemicals are to be evaporated in the fume hood.
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12. Use a fume hood for operations that might result in release of toxic chemical vapors or dust.
(Appendix B)
13. Confirm adequate hood performance before use: Keep materials stored in hoods to a
minimum, and do not allow materials to block vents or airflow.
14. Leave the hood "on" when it is not in active use if toxic substances are stored in it or if it is
uncertain whether adequate general laboratory ventilation will be maintained when it is "off."
In the event of a power outage, hood sashes should be closed.
15. No food or beverages are to be consumed or stored in laboratories or laboratory refrigerators
and freezers. No applying cosmetics, or lip balm in laboratories.
16. No hazardous chemicals are to be stored under the sink or disposed of into the sink.
17. All chemical waste containers need to be labeled with the words “HAZARDOUS WASTE”.
When the waste container is full, it must be dated and brought to the hazardous waste staging
area located in the Common Instrument Room 1259 within three (3) days with the completed
paper work (a copy of the MSDS/SDS and Hazardous Waste Inventory form). The waste will
then be transported to the Hazardous Waste Storage Room.
18. Handle and store laboratory glassware with care to avoid damage. Do not use damaged
glassware. Use extra care with Dewar flasks and other evacuated glass apparatus; shield or
wrap them to contain chemicals and fragments should implosion occur. Use equipment only
for its designed purpose.
19. Practical jokes or other behavior that might confuse, startle, or distract another worker is not
permitted.
20. Keep the work area clean and uncluttered, with chemicals and equipment properly labeled
and stored. Clean up the work area on completion of an operation or at the end of each day.
21. Compatible PPEs must be worn when working in the laboratories.
22. Inspect all PPE before and after each use and replace them periodically as necessary.
23. Wash hands and areas of exposed skin thoroughly before leaving the laboratory.
24. Ensure that appropriate eye protection, is worn by all persons, including visitors, in areas
where chemicals are stored or handled.
25. Avoid use of contact lenses in the laboratory unless necessary. If they are used, inform
Laboratory Supervisor so special precautions can be taken.
26. Follow the Feinstein’s Personal Appearance/Uniforms/Protective Equipment policy, which can
be found on HealthPort.
27. Remove laboratory coats immediately upon significant contamination. Seek information and
advice about hazards, plan appropriate protective procedures, and inform your Laboratory
Supervisor.
28. Use any other protective and emergency apparel and equipment as appropriate.
29. Use of respiratory equipment will be evaluated as needed by the Safety Office.
30. Leave lights on and place an appropriate sign on the door or an area, and provide
containment for hazardous substances in the event of an emergency, such as utility failure,
while conducting operations or experiments during off hours.
31. Be aware of unsafe conditions and report any issues/concerns to lab management
and/or Safety Office.
See The Feinstein Institute for Medical Research’s Administrative Policy & Procedure Manual on
HealthPort for details of research laboratory policies and procedure and information on appropriate
work place practices.
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5. RESPONSIBILITIES:
General Responsibility for Safety: The implementation of the Feinstein’s health and safety policies
and procedures is the responsibility of the Research Administration, Principal Investigators (PI) and
research staff. All laboratory employees are expected to participate actively in the program to ensure
its success. The Feinstein Safety Office will work in conjunction with Administration. Note: The
Chemical Hygiene Officer is part of the Feinstein Safety Office.
RESEARCH ADMINISTRATION:
1. Provide resources and support to ensure compliance with the Laboratory Safety Operations
Guidelines and the Feinstein’s Chemical Hygiene Plan (CHP).
2. Ensure that safety and health related lab findings are addressed in a timely manner.
FEINSTEIN SAFETY OFFICE:
1. Maintain a list of laboratories for to which this document is applicable to.
2. Maintain a Master List of chemicals and Material Safety Data Sheets (MSDS)/ Safety Data
Sheets (SDS) as provided by each research laboratory Principal Investigator Representative
(PI-R).
3. Develop and conduct general Feinstein Safety and Health Training. Documentation of
attendance will be maintained by the department.
4. Review the CHP at least annually and update as necessary with current applicable
regulations/laws.
5. Establish process for conducting personnel exposure monitoring and maintain records of
testing completed per laboratory.
6. Perform an initial evaluation of incidents/accidents and provide corrective actions to the PI, PIR, and Research Administration staff.
7. Review all employee occurrence reports and develop corrective action plans as needed.
8. Assist PI-R’s with the development of lab specific chemical hygiene policies and practices.
9. At a minimum, perform annual laboratory inspections and document findings/deficiencies.
10. Assist with identifying and implementing lab findings/deficiencies as necessary.
11. Supervise, monitor and maintain the chemical storage and waste room.
12. Responsible for establishing an inventory and log of chemicals placed in and removed from
the Hazardous Waste Room.
13. Collaborate with 3rd party contractor(s) to ensure appropriate management of Hazardous
Waste
PRINCIPAL INVESTIGATOR (PI):
1. Identify and assign at least one Principal Investigator Representative (PI-R) and send the PI-R
employee information to the Safety Office. If any PI-R personnel change occurs, it is the
responsibility of the PI to assign a new PI-R and communicate the change to the Safety Office.
2. Perform Hazard Risk Assessment during the design phase of research to be conducted in
their responsible laboratories.
3. Ensure overall compliance with the Feinstein CHP.
4. Be knowledgeable of all applicable legal requirements for substances used in their respective
labs.
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5. Prepare written Standard Operating Procedures (SOP) for the use of hazardous chemicals
such as, but not limited to: carcinogens, mutagens, or teratogens, specifying where and how
they will be used in their laboratory and train staff accordingly. (See Laboratory Specific
Chemical Hygiene Plan Template, Appendix J).
Principal Investigator Representative (PI-R)
Each laboratory must have a designated PI-R. This person will be appointed by the PI.
(NOTE: Even though the PI appoints a PI-R, they still have the overall responsibility of
ensuring proper regulatory compliance is maintained in their laboratories.) The PI-R is
responsible for the oversight of all aspects of the CHP.
1. Responsible for the oversight of overall laboratory compliance with the CHP and applicable
legal requirements/regulations.
2. Ensure all lab personnel are trained before any personnel works in the laboratory. Lab
personnel must also be trained whenever they are being introduced to a chemical and/or
process or when a new chemical and/or process are introduced into the lab setting. All training
records must be maintained by the department.
3. Ensure all lab personnel have read and understood the contents of the most recent version of
the CHP.
4. Maintain and update MSDSs for all chemicals in their laboratory. Forward new MSDS/SDS to
the Safety Office in timely manner.
5. Monitor procurement, use, and disposal of chemicals used in their laboratory.
6. Routinely self-assess laboratory and perform Hazard Risk Assessments. Report all
concerns/deficiencies to the Safety Office.
7. Report injury/accidents to the Safety Office and document the communication in their
personnel files.
8. Ensure that incoming chemical containers are labeled appropriately.
9. Ensure chemicals are stored and segregated properly in their laboratory.
10. Conduct PPE assessments and ensure adequate PPE is available.
11. Train all personnel on the proper use and discarding of all applicable PPE.
12. Provide and maintain an updated list of chemicals on the “share-drive” and maintain copies of
MSDS/SDS for their respective labs.
13. Semi-annually, submit list of hazardous chemical inventory to the Safety Department.
14. Ensure containers are labeled with required information.
15. Ensure staff is following proper PPE standards.
16. Date receipt and track the age of peroxide forming compounds (Appendix E).
17. Ensure the safety related facilities and equipment are functioning properly and lab personnel
have been trained on the proper use of the equipment.
Senior Specialist, Biomedical Engineer:
1. Maintain inventory of chemical fume hoods and establish hood performance program.
2. Ensure any equipment related issues/concerns are addressed in a timely manner.
3. Communicate safety and health related findings to the Safety Office.
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6. LABORATORY SPECIFIC CHEMICAL HYGIENE PLAN:
Where hazardous chemicals are used in the workplace, the principal investigator shall develop and
carry out the provisions of a written Laboratory Chemical Hygiene Plan which:
1. Informs employees of health hazards and permissible exposure limits (PELs) associated with
hazardous chemicals in that laboratory;
2. Shall be readily available to employees and regulatory agencies upon request;
3. Shall include each of the following elements and shall indicate specific measures that the
department will take to ensure laboratory employee safety:
a. Standard operating procedures (SOP) incorporating safety and health considerations
when laboratory work involves the use of hazardous chemicals;
b. Criteria that the laboratory will use to determine and implement control measures for
reducing employee exposure to hazardous chemicals including engineering controls, the
use of personal protective equipment and hygiene practices giving particular attention to
the selection of control measures for chemicals that are known to be extremely
hazardous;
c.
Requirements that laboratory hoods and other protective equipment are functioning
properly and specific measures that shall be taken to ensure proper and adequate
performance of such equipment;
d. Provisions for employee information and training;
e. Proper identification, labeling and training requirements when using peroxide forming
chemicals.( Appendix E )
f.
The circumstances under which a particular laboratory operation, procedure, or activity
shall require prior approval from the department or the Laboratory Supervisor before
implementation;
g. Designation of personnel responsible for implementation of the Chemical Hygiene Plan
and provisions for additional employee protection for work with particularly hazardous
substances. These include "select carcinogens," reproductive toxins and substances that
have a high degree of acute toxicity. (Appendix C )
Specific considerations shall be given to the following provisions, which shall be included
where appropriate:
a. Establishment of a designated area;
b. Use of containment devices such as laboratory hoods or glove boxes;
c.
Procedures for safe removal of contaminated waste; and
d. Decontamination procedures.
4.
The PI should review and evaluate the effectiveness of the Laboratory Specific Chemical
Hygiene Plan routinely and update it as necessary. The list of PI-Rs will be reviewed annually
by Research Administration. PIs should notify the Feinstein Safety Office of changes.
7. CHEMICAL INVENTORY:
A chemical inventory is submitted bi-annually, listing all the hazardous and extremely hazardous
chemicals in the laboratory. Chemicals listed are those classified as hazardous by the Department of
Transportation (DOT), the Environmental Protection Agency (EPA), Occupational Health and Safety
Administration (OSHA), NIOSH, IARC, or displaying a 2 or greater number in any section of the
National Fire Protection Association (NFPA) diamond and the Department of Homeland Security’s List
of Chemicals of Interest (COI).
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In accordance with OSHA’s revised Hazard Communication Standard (HCS) with the Globally
Harmonized System (GHS) hazard rating numbers are inverted compared to the NFPA system. In the
GHS system the number 1 is the most hazardous rating and the number 4 is the least hazardous
rating.
Chemicals are listed alphabetically. Other information provided on the chemical inventory includes,
CAS #, manufacturer, container size, physical form, average quantities on hand and storage areas.
Inventories are computerized to provide the capability of sorting according to chemical name, CAS #,
researcher, or location. Inventories are to be updated routinely as new chemicals are received or
have been disposed. A complete chemical inventory is maintained on a “share-drive” and is available
to all laboratories as a “read-only” file.
8. MATERIAL SAFETY DATA SHEET (MSDS)/SAFETY DATA SHEETS (SDS):
MSDS/SDS sheets are sent by the manufacturer and are also available through the Internet. All
documentation for MSDS/SDS requests shall be kept on file with the Principal Investigator’s
Representative.
The MSDS/SDS are in alphabetical order along with a chemical inventory of each laboratory. The
laboratory relies on the chemical manufacturer's information to ascertain whether or not the chemical
is hazardous, and to determine what types of hazards it presents, safety guidance, and emergency
response.
The responsibility for obtaining, evaluating and maintaining MSDS/SDS is assigned to each laboratory
PI and the PI-R/Laboratory Supervisor.
The MSDS for each chemical is located in each laboratory and Feinstein Safety Office. MSDS/SDS
for hazardous materials are readily accessible to employees during each work shift.
The location of these MSDS’s/SDS’s, along with reference materials, will be addressed in the
Laboratory Specific CHP or written Hazard Communication Program.
*Note: June 1, 2015 will be the deadline to ensure compliance with the OSHA Hazard
Communication (HazCom) & Global Harmonization System (GHS) update. The requirement
includes updating workplace labeling and hazard communication program to ensure
compliance with the update and provide additional employee training for newly identified
physical or health hazards.
9. CHEMICAL PROCUREMENT, DISTRIBUTION, MANAGEMENT AND STORAGE:
Chemical procurement, distribution and storage process must be managed by the PI-R/Laboratory
Supervisor.
PROCUREMENT:
Laboratory staff needs the approval of Research Administration to purchase chemicals by nonstandard ordering methods. Chemical inventory and MSDS/SDS files are to be updated by the
laboratory accordingly.
DISTRIBUTION:
All substances shipped to the Feinstein are received at the Receiving Department prior to delivery to
the ultimate recipient. Special care and attention should be given when planning to move chemicals
from one area to another to minimize the possibility of accidental exposure and release. Glass bottles
should be placed in approved glass bottle carriers; chemical bottles should be carried using secondary
containment, and stable carts. Routes taken during the move should be reviewed and evaluated, and
staff should try minimizing routes with uneven terrain areas, and changes in elevation. Freight
elevators should be used whenever possible.
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STORAGE:
Chemicals must be stored by hazard classification, i.e., flammable, acids, bases, reactive, oxidizers,
should be kept segregated from each other, even those that are non-hazardous. Large volumes of
chemicals are to be stored in cabinets used for chemical storage only. Any flammable material, which
must be refrigerated, must be stored in a properly UL listed or approved electrical compliant appliance
(i.e., explosion proof/flammable refrigerator/freezers) based on the division and classification rating
needed for the hazard. Make sure incompatible chemicals are not stored together. (See Incompatible
Chemical List, Appendix H) No food is permitted in these refrigerators.
COMBUSTIBLE LIQUID: Any liquid having a flash point above 100 F and below 200F
FLAMMABLE LIQUID:
Any liquid having a flash point below 100 F
FLASH POINT:
The minimum temperature at which a liquid gives off vapors in sufficient
concentrations to allow the substance to ignite.
Excessive storage of laboratory chemicals presents a safety problem. Efforts should be made to
reduce the storage of chemicals. Quantities are minimized to the smallest quantity possible.
Chemical storage on bench tops and in hoods is deemed potential hazards for spills and releases into
the atmosphere therefore quantities must be maintained to the smallest quantities possible. Chemical
stock in use should be maintained in cabinets to provide some containment and separation. Large
volumes of Extremely Hazardous Chemicals (NFPA rating of 3 or 4 / GHS rating 1 or 2) should be
stored in the Chemical Storage Room located on ground floor of the Feinstein or other designated
areas. Excess quantities of these chemicals cannot be stored in the individual laboratories because
they pose significant risk to the building’s occupants if spilled.
Toxic chemicals, including carcinogens, are stored in storage areas in a plastic chemical resistant
secondary containment bin. Cabinets with this type of chemical storage will read, "CAUTION: HIGH
HAZARD OR CANCER-SUSPECT AGENT." The Feinstein Safety Office, according to federal and
state regulations, maintains a separate inventory list of carcinogens and suspected carcinogens.
(See Appendix C)
Cylinders of compressed gases are properly secured, i.e., strapped or chained to a wall or bench tops,
and must be capped when not in use. These cylinders must be hydrostatically tested and stamped
every 10 years. In addition, flammable and oxidizing gases cannot be stored together. Empty and full
containers must be stored separately and labeled. (See NSUH Safety Manual – Compressed Gas
Cylinder Handling Policy)
10. LABELING:
The OSHA Laboratory Safety Standard contains specific labeling requirements. Labeling must be
provided for all hazardous chemicals that are shipped and used in the laboratories. Labels must be in
conformance of NYSDEC, and EPA right-to-know laws, as well as the OSHA hazard communication
standard, 29 CFR 1910.1200. (see Appendix D)
LABELING OF CONTAINERS: All laboratory personnel shall ensure that labels on incoming
containers of hazardous chemicals are not removed or defaced and that all chemicals are coded
according to NFPA 704 (Hazard Identification Rating System) or the GHS hazard number rating. (See
Appendix D - Chemical Hazard Labeling System) All chemical bottles must include chemical name,
hazard identification, manufacturer, the appropriate hazard signal words and pictograms. The wording
must be legible and in English.
CHEMICALS DEVELOPED IN THE LABORATORY: The following provisions shall apply to chemical
substances developed in the laboratory.
1. If the composition of chemical substance, produced for laboratory use is known, the PI shall
determine if it is a hazardous chemical as defined by the OSHA Hazard Communication
Standard. If the chemical is determined to be hazardous, the PI/PI-R shall provide appropriate
training as required by this plan (see Employee Training Section).
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2. If the chemical produced is a byproduct whose composition is not known, the PI shall assume
that the substance is hazardous and shall provide appropriate training as required by this plan.
INCOMING CONTAINERS: It is Feinstein policy to require that suppliers of chemical products label
their materials in accordance with the OSHA Hazard Communication Standard. As a minimum,
chemical name, hazard warnings, and the name and address of the manufacturer or importer should
be found on containers of hazardous substances. No container will be accepted unless it is properly
labeled with the required information. All laboratory personnel are responsible for ensuring that
incoming containers are labeled with required information. If a container is received without the
required information, the manufacturer will be required to provide properly labeled containers.
11. ENGINEERING CONTROLS:
Eyewash fountains are inspected each week and records maintained by each laboratory. Eyewash
Check Sheets are posted on the wall by each eyewash station.
Safety showers are inspected, and tested annually and flow tested quarterly by the Engineering and
Maintenance Department. Records are maintained by Engineering.
Fire extinguishers are inspected monthly by the Engineering and Maintenance Department, and
annually by an outside vendor.
Cold rooms have provisions for rapid escape, a quick exit egress during the event of an electrical
failure or fire, and they should be able to release or open easily from the inside of the cold room.
Laboratory rooms shall have proper ventilation, and flow rates may be adjusted as designated by the
hazards associated within the laboratory, per OSHA, NIOSH, CDC, AIA, and ASHRAE.
EQUIPMENT MAINTENANCE: The Laboratory SOP’s shall include a requirement that hoods and
other protective equipment are functioning properly and specific measures shall be taken to ensure
proper and adequate performance of such equipment. It is the responsibility of each PI-R to ensure
that all laboratory employees within his or her laboratory are trained in the safe use of laboratory
hoods.
HOOD INVENTORY: The Biomedical Engineer will maintain an inventory of all laboratory hoods and
their locations throughout the facility.
HOOD DEFICIENCIES: The PI-R will be responsible for reporting any known hood deficiencies to
Engineering. If a hood is deemed deficient, a sign will be placed on the outer sash until repaired.
Deficient hoods are not to be used for any reason.
12. PERSONAL PROTECTIVE EQUIPMENT (PPE):
Employees are required to wear gloves when the employee has the potential for direct skin contact
with blood, hazardous chemicals, and infectious materials. The Feinstein is a latex-free facility. Nitrile
and vinyl gloves are available depending on the type of activity and the needs of the employee. Where
indicated by the MSDS/SDS, gloves made of different material such as Butyl, Neoprene etc. must be
purchased and available for employee use.
Laboratory coats are to be worn only in the laboratory area and are to be buttoned to protect the
employee's clothing. Lab coats/aprons must be made of compatible material for the chemical and/or
operation in use (ex. Fire resistant material when working with flammable chemicals).
Goggles or chin-length face shields are worn to prevent splashes or sprays of blood, infectious
materials, or hazardous chemicals if there is a potential for eye, nose, or mouth contamination. This
equipment is to be located in each laboratory.
Where the use of respirators is deemed necessary to prevent exposure above permissible exposure
limits, the Feinstein shall provide, at no cost to the employee, the proper respiratory equipment as
determined by the Feinstein Safety Office and Corporate Employee Health Services. Prior to use of
any respiratory protective equipment, employees will:
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1. Be deemed physically capable of wearing a respirator by a licensed physician;
2. Be trained in the proper use, care, cleaning and storage of respiratory protective equipment;
3. Be initially fit tested for a respirator appropriate to the hazard; and
4. Be annually refitted to assure an adequate fit is maintained.
All personal protective equipment is doffed before leaving the work area.
13. WASTE REMOVAL & DISPOSAL:
The prevention of harm to people, other organisms, and the environment resulting from the improper
disposal of hazardous materials such as laboratory chemicals is the pinnacle of the waste disposal
program at the Feinstein. Employees, students and visiting scientists working with hazardous
chemicals must follow the waste disposal program (See Appendix F, Waste Disposal). All disposals
are done in accordance with the NYS Department of Environmental Conservation and EPA regulations
and local regulations (See Appendix G, Great Neck Sewer Use Ordinance).
All waste must be evaluated and segregated in accordance to its appropriate waste stream.
Infectious waste is collected by our Environmental Services Department and is autoclaved prior to
being transported by a contracted outside vendor. Sharps waste is collected and transported by a
contracted outside vendor. Chemicals and hazardous waste are collected in the Hazardous Waste
Storage Room. A contracted outside vendor transports waste from the main accumulation area to a
permitted Treatment Storage and Disposal Facility (TSDF). Indiscriminate disposal by pouring waste
chemicals down the drain or adding them to mixed refuse for landfill burial is unacceptable. Hoods are
not to be used as a means of disposal for volatile chemicals.
14. SPILLS AND ACCIDENTS:
Eye contact: promptly flush eyes with water for a prolonged period (15 minutes) and seek
medical attention in the Emergency Department.
Ingestion: Seek medical attention in the Emergency Department.
Skin contact: Promptly flush the affected area with water and remove any contaminated
clothing. Use a safety shower when contact is extensive. Seek medical attention in the
Emergency Department.
Incidental Spill Cleanup: Using appropriate personal protective equipment, promptly clean
up spills using the standardized spill kits and dispose of all properly. If further assistance is
needed, dial 1099 (Emergency Hotline) who will notify the Feinstein Safety Office or designee.
Always inform your Laboratory Supervisor and, if necessary, seek immediate medical
attention. Fill out a Chemical Spill Log, FEINSTEIN Event Tracking Report (See Appendix I),
and if applicable, Health System’s Employee Injury/Illness Occurrence Report Form, which is
found on HealthPort. Copies of all forms must be submitted to Research Administration.
Chemical spills in the laboratory should be cleaned up immediately. Consideration to the response of
any spill is:
1. Identification of material spilled
2. Volume of the material spilled
3. Toxicity of materials and specific hazards
4. Requirements of PPE
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The first determination of any spills is the quantifying of the spill and incidental or large unmanageable
spill by area staff. An incidental spill is one that meets the following requirements:

Quantity of material spilled is small and can be easily contained and decontaminated,

The chemical is not highly toxic or flammable,

The risk of personal contamination is low,
Each laboratory is equipped with a standardized spill kit. All laboratory staff is trained on the use of
the spill kit. Spill kits should be checked periodically for missing supplies. Laboratory staff should
inform the Safety Office when items need to be re-stocked.
Non-incidental spills are categorized as any spill of extremely hazardous chemicals or other hazardous
chemical in quantities that could pose a severe health hazard to staff. Any non-incidental spill cleanup must be completed by properly trained members of the Feinstein Safety Office or the Division of
Corporate Security and Emergency Management.
If staff determines that the spill is non-incidental, then:

A spill should be contained as much as possible, i.e., using absorbing pads/sock.

All staff should be removed from the area or laboratory, and it should be taped off with
caution tape by security officer.

Dial 1099 (Emergency Hotline). Provide your name, department, nature of the spill,
immediate contact information, and your exact location.

If a trained member of the Safety Office cannot be reached, dial 719-5000 the Division of
Corporate Security and Emergency Management, and inform them of the material spilled,
volume, and location of incident.

Complete spill incident log.

Chemical Inventory and MSDS/SDS must be made available upon request of any
responding agency and company.
15. EMPLOYEE EXPOSURE ASSESSMENT AND MONITORING:
It is Feinstein policy to perform an employee exposure assessment for hazardous chemicals regulated
by OSHA. All exposures shall be reported through the Health System’s Employee Injury/Illness
Incident Report Form, which is found on HealthPort.
EXPOSURE DETERMINATION FOR SUBSTANCE SPECIFIC STANDARDS
1. Initial monitoring - The Feinstein Safety Officer/designee shall initiate monitoring of the
employee's exposure to any substance regulated by a standard which requires monitoring, if
the Feinstein Safety Officer/designee determines there is reason to believe that exposure
levels for that substance routinely exceed the action level or PEL (Permissible Exposure
Limit).
2. Periodic monitoring - If the initial monitoring discloses employee exposure over the action level
or PEL, the Research Administration and Employee Health Services will comply with the
exposure monitoring provisions of the relevant OSHA standard.
3. Termination of monitoring - Monitoring may be terminated in accordance with the relevant
OSHA standard.
4. Employee notification of monitoring results - Research Administration, Employee Health
Services and the Feinstein Safety Officer shall, within 15 days after the receipt of any
monitoring results, notify the employee of these results in writing either individually or by
posting results in an appropriate location that is accessible to employees.
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5. The person responsible for determining the need for monitoring employee exposure is the PI/
PI-R or Feinstein Safety Officer/designee. Research Administration, with the assistance of
Employee Health Services will be responsible for ensuring surveillance of employee exposure
monitoring.
EMPLOYEE EXPOSURE CARE AND FOLLOW-UP
The Feinstein shall provide all employees who work with hazardous chemicals an opportunity to
receive medical attention (employee health service or the emergency department), including any
follow-up examinations which the examining physician determines to be necessary, under the
following circumstances:
a. Whenever an employee develops signs or symptoms associated with a hazardous chemical to
which the employee may have been exposed in the laboratory;
b. As prescribed by the particular standard where exposure monitoring reveals an exposure level
routinely above the action level or PEL, for an OSHA regulated substance for which there are
exposure monitoring and medical surveillance requirements;
c.
If an event occurs in the work area such as a spill, leak, explosion or other occurrence
resulting in the likelihood of a hazardous exposure, the affected employee shall be provided
an opportunity for a medical consultation. Such consultation shall be for the purpose of
determining the need for a medical examination. All medical examinations and consultations
should be coordinated through Research Administration and Employee Health Services
INFORMATION PROVIDED TO THE PHYSICIAN: In the event of a possible exposure incident, the
PI or PI-R will fill out the Health System’s Employee Injury/Illness Occurrence Report Form providing
copies to the examining physician, Risk Management, Research Administration, and the Feinstein
Safety Office.
PHYSICIAN'S WRITTEN OPINION: For examination or consultation required under this standard, the
institute shall obtain a written opinion from the examining physician. The physician shall inform the
employee of the results of the examination and provide the Feinstein with a copy.
ROUTINE EXPOSURES OVER PELs FOR SUBSTANCE SPECIFIC STANDARDS
1. If air monitoring results indicate that laboratory employee exposures are above the limits
prescribed in the OSHA substance specific standards, medical monitoring is provided as
required in the applicable standard for the regulated substance. The person responsible for
establishing the need for employee medical monitoring is Employee Health Services.
2. Exposure Evaluation Following an Incident: The initial evaluation of an incident for possible
overexposure shall be conducted by Employee Health Services, who will establish the need
for a medical consultation/examination.
RECORDKEEPING
Research Administration and Employee Health Services shall establish and maintain an accurate
record of any measurements taken to monitor employee exposures and any medical consultation and
examinations including tests or written opinions required by this plan. A record of all laboratory
surveys conducted, to include measurements of equipment performance, shall be maintained by the
Principal Investigator Representative and a copy for Research Administration.
Research Administration shall assure that such records are maintained transferred and made
available in accordance with 29 CFR 1910.20.
16. EMPLOYEE TRAINING:
The purpose of this section is to outline a program of laboratory employee education and training on
hazardous chemicals. A description of how employees are to be trained and the contents of the
training program are provided.
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POLICY & ASSIGNED RESPONSIBILITIES: All laboratory employees are to participate in an annual
education and training program. All new employees are required to attend the Feinstein orientation
program. New employees shall be informed about the Chemical Hygiene Plan and the Standard
Operating Procedures by the PI/PI-R. Refresher information shall be provided at scheduled intervals
as determined by Research Administration, but at least annually. Laboratory employees will be
informed about the hazards in their normal work areas as well as hazards in other areas where they
may be required to work. Whenever a new hazard is introduced into a work area, employees will be
informed of the new hazard and receive the appropriate training.
INFORMATION REQUIREMENTS: Employees shall be informed of:
1. The contents of this plan and its appendices, which shall be made available to employees.
2. The location and availability of the Feinstein and Laboratory Specific Chemical Hygiene Plans.
3. The Permissible Exposure Limits for OSHA regulated substances, or recommended exposure
limits for other hazardous chemicals where there is no applicable OSHA standard.
4. Signs and symptoms associated with exposures to hazardous chemicals used in the
laboratory.
5. The location and availability of known reference material on the hazards, safe handling,
storage and disposal of hazardous chemicals found in the laboratory including, but not limited
to, Material Safety Data Sheets received from the chemical supplier.
6. Elements of Occupational Health/Industrial Hygiene.
7. How to read and use MSDS/SDS and labels.
TRAINING REQUIREMENTS: Employee training shall include:
1. Methods and observations that may be used to detect the presence or release of a hazardous
chemical (such as monitoring conducted by the qualified personnel, continuous monitoring
devices, visual appearance or odor of hazardous chemicals when being released, etc.).
2. The physical and health hazards of chemicals in the work area.
3. The measures employees can take to protect themselves from these hazards; including
specific procedures the department has implemented to protect employees from exposure to
hazardous chemicals such as appropriate work practices, emergency procedures, and
personal protective equipment.
4. The employee shall be trained on the applicable details of the Laboratory Specific Chemical
Hygiene Plan and Standard Operating Procedures.
5. Classes of hazards such as flammables, corrosives, toxins, and reactives.
6. MSDS/SDS for products, which are representative of each hazard class, will be discussed in
detail.
7. Proper disposal of waste chemicals, to include the fact that no chemical may be disposed of in
the sanitary sewer system.
8. Spill response plan.
17. ACCESSIBILITY:
This document is available to any Feinstein employee engaged in the laboratory use of hazardous
chemicals, or their designated representative. It is also available upon request to any local, state or
federal regulatory representatives.
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Appendices
A.
Flammable Storage Supplemental Material
B.
Fume Hood Use
C.
Lists of Carcinogens and Reproductive Toxicants
D.
Chemical Hazard Material Labeling System
E.
Peroxide Forming Chemicals
F.
Waste Disposal
G.
Great Neck Sewer Use Ordinance
H.
Incompatible Chemical List
I.
Chemical Spill Log & Feinstein Event Tracking Form
J.
Laboratory Specific Chemical Hygiene Plan/SOP Template
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