Survey ID#__________________
POS Customer Feedback Given? Yes 
UNIVERSITY OF CALIFORNIA, IRVINE
LABORATORY SAFETY SURVEY SECTION A
PI SUMMARY
For each survey, complete the following information for survey scope:
Date:
P.I.:
P.I. Phone: Day
School/Dept:
Bldg Name:
Room #s:
Last Survey:
NIGHT
SR Contact:
SR Contact Phone: Day
# of Personnel in Lab(s):
Dept Administrator/Manager:
Surveyor(s):
NIGHT
Answer every question by checking “Yes” or “No”, circling where appropriate, and noting which rooms where present.
#
Characteristics of Lab/Research
Yes
No
Rooms where applicable
1.
Email Alvin S with type/location.
2.
Local Exhaust other than Fumehoods? (e.g.snorkel, slothood, necropsy,
toxic gas cabinet, ductless chemical hood) Circle
Chemical fume hoods have in-tact green EH&S sticker?
3.
Lab uses/fabricates nanomaterials?
Email Rebecca Lally: PI and location
4.
Toxic Gases? (DOT Division 2.3) Circle
Email Rebecca Lally: PI and type
5.
6.
Does your lab engage in any outside field work?
Other unusual hazards associated with research or lab?
Email Angela Geissbuhler: PI and short description
Email School Coordinator
Email Alvin S with location.
Lab Representative’s Acknowledgement of Receipt of Lab Safety Survey Courtesy Notice Items Require Immediate Action Within 2 Business Days:
_______________________________________________________________
Print Name
Signature
Date
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LABORATORY SAFETY SURVEY SECTION B
Y
1.
2.
ADMINISTRATIVE
Work unit has completed all SOS milestones?
 Designation of SR
 Safety Training Self-Assessments
 Required EHS training transcripts
 Signatures on:
o Hazard Assessment & Corrections
o PPE Assessment
o SOPs where needed
Is current signage present and accurate? Post if missing.
 In Case of Emergency door placard (ENI)
 UCI or UCIMC Emergency Procedures Flipchart (all blue
or multi-colored)
 UC Irvine Injuries & Medical Treatment (10/18/05)
 How to Access Required Safety Information (11/28/05)
 Hazardous Waste Guidelines Flyer (Ver. 3.0)
 Hazard Communication Signs & Labels (BSL2, Biohazard,
Rad, Carcinogen, Poison, Oxidizer, Flamm, Corrosive,
Hot)
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
PHYSICAL ENVIRONMENT
Are tippable items >42” high seismically secured?
Are heavy/hard items secured/limited in height?
Are cabinet doors secured?
Are storage shelves provided with lips or are cords taut?
Is storage kept at least 18” below sprinkler heads and
ceiling throughout room or area?
Are aisles clear and unobstructed (36” lab aisles, 44”
main aisles)?
Is housekeeping up-to-standards?
 trip hazards
 spilled chemicals (residuals)
 paper clutter on work surfaces and walls
 stacked broken equipment
 old, tattered, stained bench pads
Is floor in good repair to allow adequate cleaning?
Chairs and other furniture used in laboratory work are
covered with a non-fabric material that is easily
decontaminated?
Are ceiling tiles/panels in reasonable condition (not
substantially damaged, moldy, or missing)?
Is lab under negative pressure relative to corridor?
FIRE/LIFE SAFETY
Does staff know evacuation assembly location?
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N
N/A
R
COMMENTS
Check for Lab Core
Safety completion.
Post most current
versions if needed.
Note specifics:
Surveyor:
 Urgent Item
notice provided?
Surveyor: If not
immediately point
out Emergency
Procedures poster
in hallway;
advertise Volunteer
Opportunities
LABORATORY SAFETY SURVEY SECTION B
Y
15. Does staff know how to respond to emergencies?
16. Does staff know where 1st Aid supplies are located?
17. Are exit corridors and doors free from obstruction created
by improper storage or arrangement of furniture?
18. Do fire doors and doors to hazardous areas self-close and
latch properly?
19. Are fire extinguishers provided within 50 feet of the lab,
fully charged, pin and security seal in place, and up-todate maintenance tag?
20. Are trash receptacles and paper located away heat
sources?
21. Are fire alarm bells/horns/strobes free of obstruction that
would hamper the operation or reduce the sound?
22. Is emergency equipment (safety showers, fire alarm pull
stations and fire extinguishers) physically and visually
accessible?
23. Refrigerators used are appropriate for the location and
items stored? (No domestics w/in 8 ft of flammables,
Flammable Material Storage refr. for flammables)
ELECTRICAL/MECHANICAL SAFETY
24. Are electrical cords and plugs in good repair, not cracked,
broken, or frayed?
25. Are wall receptacles in good repair (not broken, covers in
place, etc.)?
26. Is the area free of multi-plug (gang-plug) adapters?
27. Are extension cords being used only on a temporary or
emergency basis?
28. Are there fixed or portable GFCI devices used in areas
that are frequently wet (within 6' of a water source)?
29. Are belts, pulleys, sprockets and chains, shafting, or other
rotating parts of mechanical equipment properly guarded
(guard openings must be less than 1/2")?
30. Do electrical panels or disconnects have 3' of clear space
in front of them?
BIOLOGICAL SAFETY
31. Does lab have a current IBC approval?
When: Bacteria; virus; rDNA;
human/primate blood/blood products/cell
lines/tissue/fluids;
yeasts; fungus; parasites; prions; rickettsias; transgenic
plants/animals;
Select Agents; human gene therapy?
32. Has applicable staff taken Bloodborne Pathogens training
within last 12 months?
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N
N/A
R
COMMENTS
Surveyor: If not
immediately review
Flipchart Tab on
Emergencies.
Surveyor:
 Urgent Item
notice provided?
Surveyor:
 Urgent Item
notice provided?
Surveyor: Label &
 Urgent Item
notice provided?
Surveyor: Label &
 Urgent Item
notice provided?
Surveyor:
 Urgent Item
notice provided?
For >BSL2 workers.
LABORATORY SAFETY SURVEY SECTION B
Y
N
33. Is lab using correct color biowaste bag? (Red for BSL2,
BSL3 PIs--no orange bags; white OK for BSL1 only PIs)
34. Are bio-waste containers:
 Labeled with the word “Biohazard” and the
biohazard symbol?
 Lid secured-in-place w/o obstructions?
35. Is red bag waste disposed through EH&S? (EVS at
UCIMC).
36. Do biosafety cabinets have:
 A HEPA Vacu-Guard to protect house
vacuum? (BSL2, BSL 3 labs)
 Secondary containment for waste flasks
when located on the floor?
37. Are biological safety cabinets certified annually or posted
"Caution: not certified for > BSL2 work"?
N/A
R
COMMENTS
PI Program, not lab.
SHARPS MANAGEMENT
38. Bio-sharps Management: needles, razor blades and
Pasteur pipettes disposed properly (rigid, plastic sharps
container; For pipettes, Safe-Keepers are acceptable)?
39. Are non-biohazardous sharp items, (broken glass and
pointed plastic items) disposed of in a broken glass
container?
CONTROLLED SUBSTANCES (CS) & SELECT AGENTS
40. Inventory usage log maintained? CS
SA
41. Adequate storage security?
CS
SA
42. Knows how to dispose material in accordance with
UCI procedures?
CHEMICAL SAFETY
CS
SA
43. Is lab staff keeping CiBRTrac chemical inventories
current within campus guidelines? (For Chemistry
Department, the system is ChemInnovation)
Surveyors:
Research CiBRTRac and
write date here:
44. Does staff know how to access the campus Chemical
Hygiene Plan? (Some work units fall under Haz Comm
Std like Willed Body Program)
45. Are hazardous chemical container labels readable with
regard to chemical name and hazards?
46. Are chemical containers in good condition (no leaking,
cracked caps, rusting, crystals around neck)?
Surveyor:
Show how if needed.
47. Are chemical containers kept securely closed when not in
active use?
48. Are containers of liquid hazardous chemicals over 1
gallon capacity stored below 5 feet high?
49. Peroxide forming chemicals: lab demonstrates good grasp
of dating containers, testing for peroxides, and/or
disposing when expired.
50. Is the operation of eyewash/safety checked monthly? (At
UCIMC bar-code system; confirm that staff observes
testing).
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Surveyor:
 Urgent Item
notice provided?
LABORATORY SAFETY SURVEY SECTION B
Y
N
N/A
51. Amounts of flammables outside of approved storage OK?
(5 gallons outside of storage per area/room)
52. Are in-use flammables located away from heat and
ignition sources? (~3 feet).
R
COMMENTS
Surveyor:
 Urgent Item
notice provided?
53. Are incompatible chemical/wastes separated by distance
or partition?
54. Are corrosive liquids, including wastes, stored below
shoulder level?
55. Are employees instructed in incidental spill response?
56. Do centrifuges have covers that are utilized during use?
57. Is lab using fume hood correctly?
 back of the fume hood clear of obstructions,
equipment
 work contained past the front of the hood by 6”
 sash position does not exceed approved working
height and is down when not in use
58. Are lab-specific SOPs for handling Particularly
Hazardous Substances available with signatures? (taking
directly from containers labeled with words like
carcinogenic, reproductive hazard, highly toxic, explosive,
pyrophoric/air reactive, or water reactive)
HAZARDOUS CHEMICAL WASTE
59. Are wastes appropriately labeled?
60. Are wastes in secondary containment?
61. Are wastes sent to EH&S within 6 months?
PERSONAL PROTECTIVE EQUIPMENT (PPE) and HYGIENE
62. Is PPE provided (may include safety glasses, goggles,
gloves, aprons, face shields)?
63. Lab workers wear closed-toe shoes and lab coat?
64. Is PPE stored in a clean and sanitary location?
65. Is staff conscientious removing PPE prior to exiting lab,
handling telephones, etc?
66. Have respirator/dust mask users been evaluated by EHS
for respirator use?
67. Is eating, drinking, and cosmetic use occurring only in
areas signed as “Clean Areas” and adequately separated
from hazardous materials use and storage?
68. Are refrigerators, microwaves and freezers labeled
regarding the storage of hazardous materials or food
items?
COMPRESSED GASES
69. Are gas cylinders capable of tipping secured?
70. Are valve protection caps kept on cylinders when stored?
71. Are toxic gases stored in a ventilated cabinet/fume hood?
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Surveyor:
 Urgent Item
notice provided?
Surveyor:
 Urgent Item
notice provided?
LABORATORY SAFETY SURVEY SECTION B
Y
N
N/A
R
COMMENTS
72. Are oxygen cylinders stored separately from flammable
gases and liquids (5' fire wall or 20' distance)?
SHIPPING DANGEROUS GOODS (DG)
73. Staff that package DG for shipping is current on training
to correctly package, label, and document hazardous
materials shipments leaving UC Irvine?
TOTALS for Quarterly LBSS Metric:
Comments/Other:
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Should = 73 per survey
Environmental Health & Safety Lab Inspection Program
Lab Safety Survey Courtesy Notice
Items Require Immediate Action
Within 2 Business Days
PI:______________________ Department:___________________________
SR Name: ____________________Bldg/Areas:___________________________
 Clean up spilled chemical residuals: _____________________________________________________________(SI#9).
 Clear items currently blocking exits and exit pathways: ____________________________________________(SI#17).
 Clear items blocking emergency equipment:______________________________________________________(SI#22).
 Repair broken/frayed electrical cords (submit FMR1): _____________________________________________(SI#24).
 Repair broken electrical outlet (submit FMR):____________________________________________________(SI#25).
 Remove items blocking electrical panel (within 3 feet):______________________________________________(SI#30).
 Request EH&S pick-up of failing chemical container:_______________________________________________(SI#46).
 Relocate flammables away from heat/ignition source (~ 3 feet):_______________________________________(SI#52).
 Secure gas cylinder (submit FMR if restraints needed):_____________________________________________(SI#70).
 Store toxic gas in ventilated cabinet/fume hood:___________________________________________________(SI#72).
 Other:____________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
______________________________________________________________________________
EH&S Surveyor
Date
Time
School Coordinators:
Bio Sci/SE/BME:
Engineering:
Medicine/PH:
Physical Sciences:
David Melitz
Joe Rizkallah
Chris Haug
Rama Singh
1
FMR = Facilities Management Request.
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