CODE OF PRACTICE
CONTAINMENT LEVEL 3 LABORATORY
Room:
Department:
This is a Containment Level 3 laboratory. It contains ?…. Class I microbiological safety cabinet
(insert make). It is a fully self-contained facility. An autoclave for disposal of waste is located ?….
Storage of samples is in the laboratory. There is a small entrance lobby to the laboratory.
The location of the laboratory is:
The number of the telephone in the laboratory is
The …………..(e.g. Lab manager) holds overall responsibility for the management of this
laboratory (including supervision of safety).
The type of work carried out in this laboratory is:
A list of authorised users of the laboratory is given in Appendix 1. Other key personnel and
contacts are listed in Appendix 2.
GENERAL ARRANGEMENTS
Access
Access to the laboratory is restricted to authorised users and visitors approved by ………. (the
person named above as responsible for the management of the lab). An authorised user must
accompany visitors at all times. The laboratory door must be kept closed at all times and locked
when the room is unoccupied. Access to the room is controlled by swipe card system?(or number
key pad) located outside the main door. Only authorised persons will have their swipe cards
validated/issued with entry code for entry into the room. Continued use of the laboratory is subject
to approval by the Laboratory Supervisor, who may stop all or any work in the laboratory without
notice considered to be risk to users.
Staff Training

Safety training must precede the first encounter with retro-virus in the laboratory. The ability to
recognise hazards, assess risks, and select appropriate practices and the skill to handle retrovirus safely must be learned through careful instruction and experience supervised by expert
and responsible personnel.

No experimental procedure involving retro-virus should be performed until the laboratory
worker can demonstrate proficiency with the procedure when handling a less serious pathogen
(e.g. an empty virus)

In addition to learning safe techniques, the laboratory worker must be trained in emergency
procedures before being allowed to work unsupervised in the laboratory.
Page 1 of 22

Records will be kept of staff training using the format in Appendix 3. Initial training in the use of
this facility will be undertaken by the Laboratory Supervisor. All personnel must read the Code
of Practice as part of this training and on completion must sign their training record to say they
have read and understood the protocols and will comply with the Code at all times.

New personnel are assigned to an authorised user for a probationary period for further training
(including scientific procedures where necessary) and supervision of their work in the
Containment Level 3 laboratory until the supervisor considers the new person to have reached
an acceptable level of competence to work safely unsupervised.

When individuals have satisfactorily completed the training they will become authorised users
and their names added to the list (Appendix 1). If at anytime anyone working in the laboratory
fails to comply with the Code of Practice for any reason or in the opinion of an authorised user,
further safety training is required, they will be suspended as an authorised user pending
retraining. During this time the suspended person is not allowed to work unsupervised in the
Containment Level 3 laboratory.
Permitted Work
The Hazard Group 3 pathogens that may currently be used in the laboratory are listed in Appendix
1 and in a notice at the entrance of the room. Work that does not require Containment Level 3
containment should, whenever possible, be conducted elsewhere. For example the manipulation
of fixed or non-infectious material, the cultivation of uninfected cells, the storage of most chemicals
and the making up of buffers and media should be done in external labs.
Out of Hours Working
Working in the laboratory out of normal working hours [8am - 6pm] should be avoided and is
subject to approval by the Laboratory Supervisor. A risk assessment will be undertaken to
determine whether the particular work proposed is safe to be undertaken in an unoccupied
building where there is no one nearby to offer immediate help in the event of an accident. The
security guard should always be told of the expected completion time for the work (and be updated
if necessary) in order that they can take action if the worker fails to contact them at the expected
time.
Entry and Exit Procedures

Always remember to take your door card for entry into this facility.

Enter CL3 laboratory in the IMM room ?…. via the door that gives access to the anteroom.
Before entering the main laboratory you must put on disposable shoes, long gauntlet gloves
and your back-fastening laboratory coat. Pull the gauntlets of the gloves over the cuffs of the
gown.

You may work in the CL3 laboratory wearing a single layer of gloves when dealing with nonbiological materials. However as soon as you want to work with infectious material or if
you wish to take samples from the deep freeze or handle other biological materials, you
must put on a second pair of latex gloves over your surgical gloves. Change the outer pair of
gloves whenever you believe them to have become contaminated.
Page 2 of 22

When you want to leave, make sure all equipment and waste are disinfected appropriately
(see below). Turn off the safety cabinet and any equipment not being used. Ensure that the
bypass system of the cabinet remains on and the extractor continues to run. Discard your
outer latex gloves. If you know your gown has been contaminated or torn, dispose of it in the
autoclave bin otherwise keep it on. Return to the anteroom. Remove your gown. The gown
may be retained in the anteroom for subsequent use if it has not been contaminated or
damaged. Dispose of your gloves. Wash your hands with LabGuard. Turn off the lights if you
are the last person to leave.
Maintenance and Cleaning

When access to the laboratory is required for maintenance purposes a temporary shut down
will be implemented and the room and equipment disinfected or sterilised as appropriate.

Maintenance and repair staff working in the Containment Level 3 laboratory will be provided
with information on the nature of the hazards in the area supplemented with adequate
instruction and supervision to ensure they work safely.

Any equipment released from the laboratory for maintenance or repair must be disinfected or
sterilised by an authorised user of the laboratory before being released whether to staff within
the University or to contractors. In addition the Laboratory Supervisor must sign a release
certificate for equipment on each and every occasion of such repair or maintenance work after
she has satisfied herself that sufficient disinfecting or sterilisation has been carried out.

If it is not possible to completely disinfect or sterilise equipment potentially contaminated with
pathogens, the release certificate must give details of the parts of the equipment that remain
contaminated and the precautions that have to be taken to prevent infection. The equipment
must not be released until the Laboratory Supervisor is satisfied that the recipient understands
the measures that have to be taken to avoid infection and the matter has been discussed with
the University Biological Safety Officer.

Authorised users will undertake all cleaning in the laboratory. Individual workers are
responsible for routine cleaning and disinfection on completion of each work session. The floor
will be cleaned and disinfected at least once every two weeks by authorised users on a rota
system (see appendix 9).
Occupational Health Surveillance
All staff must register with the University Occupational Health Service before working in the
Containment Level 3 laboratory. This includes visiting workers even if they only expect to stay for a
short time. Health surveillance will be commenced and continued as necessary. Staff must inform
the University Occupational Health Service that they work in the Containment Level 3 laboratory
and provide details of the nature of their work.
Female workers should inform the head of department of their pregnancy as soon as they are
aware they are pregnant. Where necessary they will be referred to the Occupational Health
Physician for advice.
Exposure Records
Details of all persons working in the laboratory will be maintained. This will include for each person
Page 3 of 22
the type of work undertaken, the pathogens handled, any accidents or incidents occurring and the
dates (start and finish) of working in the laboratory.
Page 4 of 22
LABORATORY RULES AND PROCEDURES
Laboratory Code of Practice
The Laboratory Code of Practice must be complied with at all times. Whilst working in the
laboratory the rules set out below must be followed. A copy of the laboratory rules (see Appendix
4) is displayed in the laboratory.

Do not work in the laboratory if you are suffering from skin abrasion, cuts or conditions that
seriously impair the integrity of the skin. Protect very minor abrasions by applying plasters
before you put on your gloves. Do not apply petroleum jelly or other agents that weaken the
latex to the hands before you put on your gloves.

Do not eat, drink, chew, smoke or handle contact lenses, touch your face, eyes or hair in the
laboratory. If touching your face, glasses, eyes or hair is necessary remove your outer pair of
gloves, exit the lab, remove long gauntlet gloves and wash your hands before doing it. Storing
of food and outdoor clothing in the laboratory is banned.

Keep all laboratory doors closed because safety can be compromised by disruptions to the
ventilation system or airflow. Place a sign on the laboratory door that informs colleagues that
an experiment is in progress. Avoid opening and closing the door during this period.

Back fastening laboratory coats, disposable shoes, disposable long gauntlet must be worn at
all times whilst working in the laboratory. Contaminated laboratory coats must be autoclaved
before being discarded. You must wear conventional shoes rather than flip flops or open toe
shoes under the disposable shoes.

An outer pair of disposable gloves must be worn on top of the long gauntlet gloves for all work
with infectious material. If gloves become damaged or contaminated, remove them carefully,
wash the hands immediately, and put on new pairs of gloves. Disposable gloves must not be
reused.

All procedures that involve the handling of infectious material in open vessels must be
performed in a certified and properly functioning microbiological safety cabinet. Important
precautions for use of biological safety cabinets are given under “Biological Safety Cabinets”.

Because the major causes of laboratory infections are cuts, needle-stick injuries and
scratches, use of syringes, needles, glass Pasteur pipettes, capillary tubes, scalpels, and other
sharp instruments is prohibited. Plastic disposable alternatives must be used.

Microscope slides should be disposed of in small autoclavable sharps bin.

When pipetting always use a mechanical pipetting device, never mouth pipette.

In the event of an accident resulting in a wound immediately encourage it to bleed without
squeezing the wound. Wash thoroughly with soap and water but DO NOT SCRUB, cover with
waterproof dressing. In the event of contamination of skin, conjunctivae or mucous membrane
immediately wash thoroughly. Accidents must be reported to the Laboratory Supervisor and
the Departmental Biological Safety Officer.

Use secondary leak-proof containers to move or transfer cultures and other infectious
materials between areas where they are kept, such as freezers, centrifuges or incubators, and
biological safety cabinets.
Page 5 of 22

Always use the biological safety cabinet for ………..

Samples must be centrifuged only in the sealed, aerosol-proof, centrifuge safety container.
Close tubes containing ……….. tightly and always carry them in a rack placed in a leak proof
container when moving to and from the centrifuge. Do not overfill tubes containing …………..

All waste materials must be made safe before leaving the laboratory. Decontaminate waste
cultures and all other waste materials that are potentially contaminated with ……..(see
‘Disposal of Laboratory Waste’ and/or Appendix 8) before autoclaving?.

Keep the laboratory scrupulously clean, and decontaminate work surfaces daily with ………
followed by 70% ethanol to remove residual detergent.

Wash hands as soon as a procedure is completed, and always before leaving the laboratory
(see Entry and Exit Procedures).
Practices for Improving Containment within Biological Safety Cabinets
Biological safety cabinets provide primary protection for the laboratory worker against accidental or
inadvertent release of ……... Any procedure that involves the manipulation of liquid suspensions
or culture of ………. must be carried out within a biological safety cabinet. Always be conscious of
the fact that class I cabinets are not absolute containment devices. Disruptions in intake airflow
may increase leakage or escape of aerosols from the front opening of the cabinet. The following
additional practices are considered excellent techniques for improving containment:



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
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
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Plan the experiment in advance.
Make sure you have provided yourself with a usable stainless-steel autoclave bin, liquid
disposal container and a screw-topped plastic container for contaminated small items.
Designate areas on the work surface where clean supplies, the experimental agent,
disinfectant, and contaminated waste will be placed. Do not handle contaminated materials
over areas designated for clean materials.
Place all materials needed for the experiment into the cabinet before beginning the
experiment. When this is not possible, use a cart or bench next to the cabinet only for excess
clean material.
Use slow and deliberate movements when bringing items into or out of the cabinet. Erratic
movements will disrupt the intake airflow and cause reverse air currents that can draw aerosols
out of the cabinet. Reduce both lateral and in-and-out motions across the front opening to an
absolute minimum.
Avoid opening and closing the door during this period. Movements of colleagues near the
cabinet can also cause disruptions in the airflow.
When using the biological safety cabinet, always work at least 4 inches beyond the front
exhaust grill.
Always disinfect the surfaces of containers before removing them from the cabinet.
Remove protective gloves carefully before leaving the cabinet. Double-gloving offers an
advantage when the outer glove becomes contaminated before a task is completed. The
contaminated outer glove can be removed in the cabinet and replaced with a new one without
having to wash hands.
Never place anything on the cabinet or occlude its air intake.
Use a disinfectant trap and air filter to protect the cabinet vacuum source from contamination.
Disinfect work surfaces after the experiment has been completed and all items have been
removed from the cabinet.
Know the operational parameters of the cabinet, and do not use if any discrepancy is
suspected. Immediately stop any manipulation of the agent if the blower or exhaust ventilation
Page 6 of 22

system fails and the alarm sounds.
Always handle the heating block or Hot Air Steriliser with care. The hot air can disrupt airflow.
EMERGENCY RESPONSE GUIDELINES
The first priority is to safeguard the laboratory worker from a life-threatening situation or from the
most immediate danger to health. The following guidelines are used for responding to spills
involving materials contaminated with …………. Materials required for these tasks should be
readily available.
Medical Emergencies

In the event of an accident resulting in a wound, it should be encouraged to bleed by vigorous
irrigation under a running tap and the area washed with soap and water but DO NOT SCRUB.
Wounds should not be squeezed or pressed to promote bleeding since this may cause tissue
trauma leading to spread of any infection. The wound should be covered with a waterproof
dressing. Any contaminated skin, conjunctivae or mucous membranes should be washed
thoroughly.

In the event of an accident where there is potential exposure to a hazard group 3 pathogen
then the person should go direct to the Infectious Disease Unit (John Warin ward) at the
Churchill Hospital. Wherever possible a colleague should telephone the Unit to advise that the
person is on the way and inform the Unit of the nature of the accident. Specialist advice will be
provided by the consultants at the Unit on the use of prophylactic treatment and the taking of
blood samples etc.

Accidents must be reported to and recorded by the Laboratory Supervisor. The Safety Office
and the Occupational Health Physician should be informed immediately in the event of any
accident where exposure to a pathogen or infectious material may have occurred. A full
accident record should be prepared and forwarded to the Safety Office as soon as possible.
The source of any contamination (specimen, sample, material etc) should be clearly identified
and retained for testing if necessary.
Spills of Hazardous Materials
Spills of ………..within Biological Safety Cabinets


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
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
Keep the cabinet turned on. The functioning cabinet will contain the aerosol and prevent
significant contamination of the laboratory environment.
Persons in the vicinity of the cabinet should be alerted to the spill and advised to either leave
the laboratory or stay away from the cabinet.
If the contamination is limited to droplet size, stop the work and let the cabinet run undisturbed
for 10 min. Then, spray and wipe the interior cabinet walls, work surfaces, and equipment with
a detergent such as phenolic derivative (e.g. 2% Hycolin). Allow a 30 min contact period and
then clean the Hycolin using 70% alcohol spray.
Place the disposable disinfected items into double autoclavable bags.
Tie the bags shut and place inside the large stainless steel vessel for autoclaving.
All reusable items should either be autoclaved or thoroughly wiped with disinfectant.
Gloves should be disposed of and protective clothing should be decontaminated at the end of
the decontamination procedure.
Allow the cabinet to run for 10 min before using it again or turning it off.
Page 7 of 22

If a large spill has occurred within the cabinet (>1.0 ml) initiated procedures leading to Cabinet
Fumigation (see Appendix 6). Experienced staff should carry out this procedure.
Spills of ……….. in the Containment level 3 (CL3) Laboratory
Spills of materials containing …….. outside the biological safety cabinet generate aerosols that
can be dispersed throughout the laboratory. To reduce the risk of inhalation:
 Occupants should leave the laboratory immediately (avoiding inhaling if possible).
 The door should be closed and the laboratory should not be entered to decontaminate and
clean up the spill until the aerosol has been removed from the laboratory by the exhaust air
ventilation system. This will take ? hours for a laboratory this size, providing over ? airchanges
in the room (Room volume = ?m3; extract rate=?m3/sec). Before re-entering the laboratory, use
protective equipment that will prevent skin contact with contaminated surfaces, protect eyes
and mucous membranes from exposure to splattered materials, and prevent exposure by
secondary inhalation must be worn.
 The protective equipment includes back-fastening gown or jumpsuit, disposable gloves,
disposable shoe covers, and respirator with full-face shield.
 Assess the extent of the spill and prepare for decontamination of the laboratory by fumigation
(see Appendix 7).
Disposal of Laboratory Waste
All waste from the Containment Level 3 laboratory must be autoclaved prior to final disposal. An
autoclave for making safe of waste materials is located in the ? Building. A robust stainless steel,
leak-proof container will be used for storage and transport of waste for autoclaving. The autoclave
is validated annually and following any maintenance work to check performance.
Disinfection and Disposal of Laboratory Waste
Disinfectant
 Hycolin (a phenolic detergent) is the only disinfectant approved for use in this laboratory. No
other disinfectant should be used without seeking approval from the laboratory supervisor. Use
concentrations and contact times given in Appendix 8.
 PVC gloves must be used for handling high concentrations of Hycolin, i.e. when preparing
dilute solutions for disinfecting.
 After disinfecting waste fluid must be autoclaved. All plastic ware etc must be autoclaved
before final disposal.
Non-Contaminated General Waste (e.g. paper towels, tissues, plastic wrapper etc.)
A large stainless-steel bin fitted with an autoclave bag must be used for depositing low-hazard
waste. When the bin is two-thirds full, detach the autoclave bag from the rim and place
loosely inside – ensure that the bag is as open as possible to admit steam freely during
autoclaving. Replace the used bin with an empty one containing an autoclave bag.
Contaminated Liquid Waste
Decontaminate liquid waste by adding to Hycolin to give a final concentration of 2% and leave
overnight to decontaminate before autoclaving. Special screw top vessels for autoclaving
liquid waste are provided.
Page 8 of 22
Contaminated Sealable Plastic-ware (e.g. tissue culture flasks, centrifuge tubes etc.)
After decontaminating with 2% Hycolin close these tightly within the safety cabinet and place
inside the bin. Decontaminate larger volumes of liquid as described above.
Contaminated Non-Sealable Plastic-ware (e.g. multiwell tissue culture plates etc.)
Multiwell plates should be aspirated using a pipette or the vacuum aspirator into at a volume
with final concentration of 2% Hycolin and then soaked in a screw-topped plastic container (2
plates per pot). Contaminated items should be left to decontaminate in 2% Hycolin overnight
and then autoclaved.
Contaminated Small Items (e.g. Gilson tips, cryovials, microfuge tubes etc.)
Dispose of these in a screw-top plastic container with 2% Hycolin. Soak overnight. Secure the
top, wipe outside with 2% Hycolin and autoclave.
Contaminated Pipettes
Rinse these internally (by pipetting) with 2% Hycolin and leave to soak in the pipette canister
overnight before autoclaving.
Plastic Hemocytometers
Do not use glass counting chambers or cover glasses. An approved brand of plastic
haemocytometer is the Kova Glasstic. After adding a cell suspension to a counting chamber
within the safety cabinet, transport it to and from the microscope within a secondary
container. Dispose of even partly used chambers in the screw-top plastic container.
Radioactive Waste
 Liquid Waste: This should first be treated with 2% Hycolin and 1% Decon overnight if it is
contaminated with ……….

Solid Waste: Soak tips etc. in 2% Hycolin, 1% Decon in a dedicated container overnight.
Place the tips etc. in the Scotlab Radiation box until a special autoclave run is arranged with
the EPA Washroom staff (see below – use of autoclave).

All surfaces, gloves and equipment must be monitored after use. Radioactive contamination
must be mopped up with 2% Hycolin, 1 % Decon and tissue or gloves contaminated in this
process must be placed in Scotlab radiation box for special autoclaving.
When a special autoclave run is arranged by the person responsible for the laboratory, transfer
the infected waste stored in the Scotlab radiation box to a LIP (BIBBY STERILIN) mixed waste
autoclave bag in a stainless steel autoclave vessel. Add 50ml water to the absorbent provided by
the manufacturer to the bag. Seal the bag using the bands provided, label clearly with words
“Radioactive Waste: Fluid Cycle” and transport to the EPA Building for autoclaving.
Storage and Transport of Infectious Material
Storage at room temperature, 4C, and –20C
It is not advisable to store any material that might be contaminated under these conditions. If
infected material needs to be stored temporarily under these conditions before analysis, it
should be held in the –20C freezer in clearly labelled containers (i.e. name, date, and
description of sample) that cannot be opened accidentally. Samples stored for longer than
three months without re-labelling will be disposed without consultation.
Page 9 of 22
Storage of infectious material at –85C
All material must be in leak-proof containers that have been superficially disinfected with
Hycolin. Storage racks are provided in the –85C freezer and individuals should have trays
assigned to them and clearly label them with their names. All infectious materials stored in the
racks must be recorded by the individual worker in the appropriate section of the Excel
spreadsheet. Material should not be stored outside the racks for any reason. Any clutter is
liable to removal and destruction.
Transport of infectious material
All material handled in the containment level 3 laboratory is considered to be infectious unless
decontaminated using the methods described above. Transport of samples outside the
Containment Level 3 laboratory (which will be avoided unless absolutely necessary) will be in
UN type approved packaging with appropriate labelling. Except for material stored in the cell
bank, infectious material must only be removed from the laboratory if it is to be received in a
laboratory operating level 3 containment procedures.
Taking Notes
The aim is to minimise the use of conventional pen and paper by using networked computers. You
should use the computer provided in the workroom to record your experiments and use jotting
pads only for very temporary rough notes that you will transcribe to the computer and destroy
before leaving the lab. Do not leave paper on benches after use. The vicinity of the computer is
considered “clean” and must not be contaminated with biological material. Remove your outer pair
of gloves (if you’re wearing a second pair) before using the computer and put on a fresh pair when
returning to the cabinet.
OPERATION AND MAINTENANCE PROCEDURES
A summary of the routine operation and maintenance schedules in the laboratory is provided in
Appendix 5.
Any problems with any equipment or the operation of the laboratory should be reported to the
Laboratory Superviosr
FUMIGATION
i)
Microbiological Safety Cabinet
The microbiological safety cabinets must always be fumigated if a large spillage of
infectious material occurs within them (>1.0ml), before filters are changed or before any
maintenance work is carried out.
The detailed protocol for fumigation of the microbiological safety cabinet is given in
Appendix 6.
ii)
Laboratory
The laboratory is only likely to require fumigation in the event of a major accident involving
widespread dissemination of contamination. Minor accidents and spillages inside the
Safety Cabinet will be dealt with by surface disinfection with Hycolin (see above).
Formaldehyde fumigation of the laboratory must only be carried out by named trained
personnel and with the explicit approval of LaboratorySupervisor. The University Safety
Page 10 of 22
Office MUST be notified in advance of any such fumigation operation.
UNDER NO CIRCUMSTANCES SHOULD ANYBODY BE ALLOWED TO ENTER THE
ROOM WHILST FUMIGATION IS IN PROGRESS UNLESS THEY ARE WEARING FULL
BREATHING APPARATUS.
After fumigation the level of formaldehyde remaining in the air MUST be below 2 ppm (2.5
mg.m-3) before staff are allowed to re-enter the room. The level of formaldehyde must be
checked with a formaldemeter. The person entering the room to check the formaldehyde
levels must wear a laboratory coat, gloves and a full-face cartridge respirator. Air sampling
equipment and a suitable cartridge respirator are available from the University Safety
Office and appropriate instruction and training will be given on the use of the respirator.
The detailed protocol for fumigation of the laboratory has been validated before
commencement of work and is given in Appendix 7.
A record must be kept of all fumigations of the laboratory including date, personnel
involved and the results of air monitoring on completion of the procedure.
Page 11 of 22
APPENDIX 1
Containment Level 3 Laboratory
Authorised Users and Permitted Pathogens
Date
Authorised User's Name
Pathogen
Page 12 of 22
Authorisation Given By
APPENDIX 2
I. Key Personnel/Contacts
Laboratory Supervisor
Deputy Laboratory Supervisor
Area Safety Officer
Departmental Safety Officer
Departmental Biological Safety Officer
University Biological Safety Officer
Mr. Andrew Thompson
Tel.: 01865-(2)70819
Director of Health & Safety Services
Mr. Alan Kendall
Tel.: 01865-(2)70811
University Occupational Service
Tel.:
01865-(2)82679
II. Contacts for Accidents and Emergencies
University Security Services [24hrs]
Ambulance
Fire
89999
999
999
**Paste a copy in the lab**
Page 13 of 22
APPENDIX 3: CL3 LABORATORY ROOM
CONTAINMENT LEVEL 3 TRAINING RECORD
AND ACCESS AUTHORISATION
NAME: ......................................................
Date ................................…....................
Induction Training
Working practices,
laboratory rules,
disinfection,
waste disposal,
safety cabinets,
accidents
…………………………………………… Satisfactory/ Unsatisfactory
……………………………………………
……………………………………………
……………………………………………
……………………………………………
……………………………………………
……………………………………………
…………………………………………………… [any additional comments]
…………………………………………………………………… [signature]
…………………………………………………………..……… [print name]
Declaration
I have read and understood the Containment Level 3 Code of Practice and will comply with the Code at all
times.
……………………………………………………………… [signed]
……………………………………………………………… [print name]
Probationary Period
Supervision of work and further training in ………………………………………………
From ………………………………………………………………………………………
To
………………………………………………………………………………………
…………………………………………………………………Satisfactory/ Unsatisfactory
…………………………………………………………………..[Any additional comments]
………………………………………………………………………………..… [Signature]
…………………………………………………………………………………[print name]
Authorisation
Training has been satisfactorily completed ………………………………………… [Name]
is authorised to work unsupervised in the Containment Level 3 laboratory
…………………………………………………………………………………….[signature]
……………………………………………………………………………………print name]
Further Training
[Records should be kept of any additional training. If the person is suspended as an authorised user for
any reason it should be recorded here and a full retraining record kept]
Page 14 of 22
APPENDIX 4 - LABORATORY CODE OF PRACTICE
Laboratory Code of Practice
The Laboratory Code of Practice must be complied with at all times. Whilst working in the
laboratory the rules set out below must be followed. A copy of these laboratory rules is displayed
in the laboratory.

Do not work in the laboratory if you are suffering from skin abrasion, cuts or conditions that
seriously impair the integrity of the skin. Protect very minor abrasions by applying plasters
before you put on your gloves. Do not apply petroleum jelly or other agents that weaken the
latex to the hands before you put on your gloves.

Do not eat, drink, chew, smoke or handle contact lenses, your face, eyes or hair in the
laboratory. Storing of storing of food and outdoor clothing in the laboratory is banned.

Keep all laboratory doors closed because safety can be compromised by disruptions to the
ventilation system or airflow. Place a sign on the laboratory door that informs colleagues that
an experiment is in progress. Avoid opening and closing the door during this period.

Back fastening laboratory coats, long gauntlet gloves and disposable shoes must be worn at
all times whilst working in the laboratory. Contaminated laboratory coats must be autoclaved
before being discarded. All gloves should be disposed at the end of each session. You must
wear conventional shoes rather than flip flops or open toe shoes under the disposable shoes.

An extra pair of gloves must be worn for all work with infectious material. If gloves become
damaged or contaminated, remove them carefully, wash the hands immediately, and put on a
new pair of gloves. Disposable gloves must not be reused.

All procedures that involve the handling of infectious material in open vessels must be
performed in a certified and properly functioning microbiological safety cabinet. Important
precautions for use of biological safety cabinets are given under “Biological Safety Cabinets”.

Because the major causes of laboratory infections are cuts, needle-stick injuries and
scratches, use of syringes, needles, glass Pasteur pipettes, capillary tubes, scalpels, and other
sharp instruments is prohibited. Plastic disposable alternatives must be used.

Microscope slides should be disposed of in small autoclavable sharps bin.

When pipetting always use a mechanical pipetting device, never mouth pipette.

In the event of an accident resulting in a wound immediately encourage it to bleed, wash
thoroughly with soap and water but DO NOT SCRUB, cover with waterproof dressing. In the
event of contamination of skin, conjunctivae or mucous membrane immediately wash
thoroughly. Accidents must be reported to the Laboratory Supervisor and the Departmental
Biological Safety Officer.

Use secondary leak-proof containers to move or transfer cultures and other infectious
materials between areas where they are kept, such as freezers or incubators, and biological
safety cabinets.

Always use the biological safety cabinet for.

Samples must be centrifuged only in sealed aerosol-proof safety container. Tighten caps well
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
with the tubes still inside the biological safety cabinet. Carry tubes to and from the centrifuge in
a rack placed in a leak proof container. Do not overfill tubes.
All waste materials must be made safe before leaving the laboratory. Decontaminate waste
cultures and all other waste materials that are potentially contaminated with …..using a
phenolic detergent (see ‘Disposal of Laboratory Waste’ and/or Appendix 9) before autoclaving.

Keep the laboratory scrupulously clean, and decontaminate work surfaces daily with a
tuberculocidal phenolic detergent solution (2% Hycolin) followed by 70% ethanol to remove
residual detergent.

Wash hands as soon as a procedure is completed, and always before leaving the laboratory
(see Entry and Exit Procedures).

The Laboratory Code of Practice must be complied with at all times
……………………………………………………………………………………[Signature]
………………………………………………………………………………………[name]
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APPENDIX 5 - LABORATORY AND EQUIPMENT MAINTENANCE SCHEDULES
Maintenance schedules for the laboratory including equipment are detailed below:
Item
Action Required
MSC Class I
Inverted Microscope
Zeiss Axiovert 25C
Centrifuge (Sanyo
MSE Harrier)
CO2 Incubator (Sanyo
Incusafe
Freezer -85C (Sanyo
Chest Freezer)
Freezer -20C
(Electrolux)
Refrigerator
(Electrolux)
Water Bath
()
Carbon dioxide
Monitor
Suction Pump
MG Electric ()
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Done By
Frequency
APPENDIX 6 - FUMIGATION OF MICROBIOLOGICAL SAFETY CABINETS
1.
Switch off the cabinet fans.
2.
Fill the vaporiser with 20ml of formalin plus 20ml double-deionised water and screw on the
aluminium cap - finger tight, having checked the gasket in the cap is undamaged. Place the
vaporiser in the cabinet.
3.
Fit the closure panel/night door and fully seal the front screen and closure panel with
sealing tape to ensure there are no leaks.
4.
Post a notice on the front of the cabinet indicating fumigation is in progress.
5.
Switch the vaporiser on. This will activate the program that ensures formalin is dispersed
thoroughly in the cabinet.
6.
Leave the cabinet in this condition preferably overnight, but for a minimum of 6 hours.
7.
Before venting the formaldehyde check that no one is in the vicinity of the exhaust outlet
and the gas will not enter any open windows nearby.
10.
Exhaust the formaldehyde from the cabinet by switching on the fans and opening the
closure panel/night door slightly (remove bung if fitted or crack open) until the majority of
the formaldehyde has been exhausted. After about 5 minutes the night door may be
removed completely.
11.
Any poly-formaldehyde residue in the vaporiser may be removed by heating with water
containing a little mild detergent.
12.
Run the cabinet for at least a further 15-20 minutes to remove the last traces of
formaldehyde.
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APPENDIX 7 - FUMIGATION OF THE LABORATORY
. The procedure as described below has been validated in a trial fumigation on 10th April
2002, when thermometers, hygrometers and spore strips were used to control
environmental conditions and efficiency of the procedure.
1. If fumigating after accidental spill, make sure the ventilation system has been operating
for at least 2 hours before entering the room. Before commencing fumigation switch off all
forced air ventilation systems, extract systems and any fume cupboards and microbiological
safety cabinets in the room.
2. Check that the remote switch that will be used to exhaust the formaldehyde from the room is
working (run the extract this way for at least 5 minutes then switch off).
3. Enter the room, wearing a laboratory coat and disposable gloves, equipped with the sealing
materials, the appropriate quantities of formalin (see below) and the heater. A second person,
prepared with a respirator (but not wearing it), must remain outside as an observer in case
assistance is required.
4. The following sequence of steps should be taken where relevant:
(a) Close the door;
(b) Apply the appropriate disinfectant to any obvious spillage. For M. tuberculosis
contaminated material:
(i) Cover the spill with paper towels or other absorbent materials.
(ii) Carefully pour a freshly prepared 1 in 10 dilution of hycolin around the edges of the
spill and then into the spill. Avoid splashing.
(iii) Use paper towels to wipe up the spill working from the edges into the centre.
(iv) Clean the spill area with fresh towels soaked in disinfectant.
(v) Place the towels in double autoclavable bags and autoclave in stainless steel bin.
(c) Safety cabinets should be left open to allow entry of the fumigant;
(d) Keep the door between main Laboratory and anteroom open by using the safety cabinet
front door wedged between the door and the bench.
(e) Place a mixture of 166ml formalin plus 1,494ml water into the heater unit [calculated on
100ml formalin+900ml water per 28.3m3 of space. Laboratory volume = 41.5m 3 ];
(f) Activate the heater using the switch (placed under the heater). Plug heater in the socket
inside the Safety Cabinet and leave the room.
5. LOCK THE OUTER DOOR and effectively seal around the edges with tape and plastic
sheeting.
6. Turn on the fumigation switch using the appropriate key (switch is located outside the main
door, beside the exhausting fan main switch).
7. After a period of NOT LESS than 12 hours (the procedure is best carried out overnight), the
room must be well ventilated. Purge the space by using the remote switch to activate the
extraction system (open dampers).
8. Allow the room to purge for at least 2 hours to remove the formaldehyde.
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9. Check levels of residual formaldehyde in the room with suitable air monitoring equipment
(formaldemeter). Only enter wearing a laboratory coat, gloves and a full-face cartridge
respirator.
10. Check the room and all surfaces for formaldehyde residues and clean up as necessary.
11. Remove all sealing materials.
12. Only allow other staff to enter the room when formaldehyde levels are below 2ppm (2.5 mg per
cubic metre). Levels MUST be below 2 ppm before staff can re-enter the room.
A record must be kept of all fumigations of rooms/laboratories including date, personnel involved
and the results of air monitoring on completion of the procedure. Please note that efficiency of
routine fumigation should always be monitored by checking unexpected growth of several spore
strips placed at various positions inside the main lab.
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APPENDIX 8 - DISINFECTION POLICY
Hycolin is the only disinfectant approved for use in this laboratory. The concentrations and contact
times that should be used are given below:
Item
Concentration
Contact Time
Plastic ware
2% Hycolin solution
overnight
fully immersed
Liquids
e.g. samples, culture
supernatants etc
final concentration of 2%
Hycolin when liquid is
added
overnight
Surfaces including benches
and floors
2% Hycolin
70% ethanol
wipe over with Hycolin
follow with ethanol on
benches
Minor surface
contamination
1% Hycolin
30 min
Large spillage
fumigation
See Appendix 7 and 8
After disinfection waste fluid and paper- and/or plastic-ware must be autoclaved before final
disposal.
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Appendix 9
Rota for fortnightly disinfecting and cleaning of Containment Level 3 Laboratory to be displayed in
the laboratory.
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