1.1 -- Organization of the EHRS Handbook

Requirements for safety, occupational health and environmental protection are increasing rapidly, not only in numbers, but also in complexity. The time necessary to understand and comply with these requirements is considerable. It is therefore both logical and economical to provide investigators information in a brief and understandable language. The Environmental Health and Radiation Safety (EHRS) Handbook is designed to meet this need.

Consistent with numerous legal mandates, the EHRS Handbook makes a distinction among policies, procedures, and guides. Policies are binding requirements that are either based entirely on legal requirements, or express the desire of the University for a specific action. Procedures contain a detailed, and often step-by-step description of how a policy is implemented in a specific setting. By their very nature, procedures are specific to an operation and are often voluminous. In contrast to these, guides perform an important function by providing the necessary scientific information to assist those who must comply with policies and/or follow procedures. Whereas policies and guides have general applicability, procedures often relate to a specific operation or facility.

Based on the distinction outlined above, the EHRS Handbook contains only policies, procedures are excluded. EHRS uses several hundred procedures most other administrative units are also likely to need a variety of procedures. For this reason EHRS encourages, and in some cases requires, the availability of procedures in all areas where EHRS policies apply. The EHRS staff provides assistance in the development of procedures.

New regulations are promulgated continuously, and certain policies  require periodic revisions. Furthermore, lessons are learned from the operation of the University. All of these necessitate a mechanism for revision of various policies and guides. The EHRS Handbook is a document that will be reviewed at least annually and revised when necessary.

1.2 – Classification of Safety Infractions

The policy on corrective actions must rely upon a number of parameters, including the probability of an adverse effect, the regulatory requirements, and common sense.  There is an increasing recognition that risk based decisions are more cost effective and lead to safer conditions than the previously held notion that a condition or an action is either safe or unsafe.  A noted safety infraction requires an immediate corrective action from the principal investigator or supervisor. The lack of response, corrective action or a repeated violation for a severe safety infraction will be reported to the proper committee (Environmental Health and Safety Committee, Radiation Safety Committee, IBC, etc.) and appropriate actions will be taken.

1.3 – Assurance on Hazardous Procedures

An important element of a well functioning safety program is appropriate planning for various services.  A major ingredient of the planning process is the availability of information on the nature and quantity of hazardous materials that are used by various investigators. Form EHRS 1.3F-001, Assurance on Hazardous Procedures, is designed to accommodate this requirement. Every investigator is required to complete this form whenever a new project is being planned, or a significant redirection of an existing project is being contemplated. EHRS 1.3F-001 is normally provided to investigators by the Office of Sponsored Projects.  Subsequently, the completed form is referred to EHRS for review and appropriate action. Principal Investigators must provide the completed form directly to EHRS for projects that are not processed through the Office of Sponsored Projects.

1.4 – Principal Investigators and Supervisors

The facilities of Temple University comprise a broad and diverse spectrum of working spaces, laboratories, storage areas, and multi-use facilities.  Each facility has its own purpose, and consequently, its own unique requirements for safety practices and procedures.  The Environmental Health and Safety (EHRS) policy relies upon individual responsibility in implementing its program.  Every space on the campus includ­ing corridors, storage areas, and machinery spaces must have a designated principal investigator or supervisor.  These individuals are respon­sible for communi­cating and imple­ment­ing the EHRS’ policies and procedures.

The PI/Supervisor is responsible for:

• ensuring the health and safety of workers under his or her direction or supervision,
• ensuring that personnel working under their supervision receive appropriate safety training,
• ensuring that his/her employees, staff and visitors comply with relevant regulations and Temple policies and procedures, and
• providing information regarding safety, security and health risk of operations to his/her employees as result of their duties.

1.5 – Vacating Laboratory Spaces

Vacated laboratory or similar space as determined in 1.7, vacated for renovation, reconstruction, or permanent move of the occupant must be decontaminated and cleaned. The principal investigator or supervisor must certify that all known hazardous materials and Controlled Substances have been removed and other individuals can safely enter the vacated area.

Accordingly, the vacated area must be left free of hazardous materials, Controlled Substances as well as debris. The principal investigator or supervisor must provide the EHRS with a completed “Certificate of Vacancy” form before outside personnel can enter the laboratory.

1.6 – EHS Safety Committee

Temple University is committed to providing a safe environment that is free from recognizable hazards for all its students, employees, patients and visitors.  It is the University’s policy to comply with all applicable local, state and federal regulations.

Working with hazardous materials is a privilege that University grants to its faculty, staff and students. This privilege may be suspended or revoked if any individual violates University Policies and/or takes any action that might compromise the safe environment that Temple seeks to provide.

In order to ensure safe practices, the Senior Vice President for the Health Sciences Center and the Provost established the EHS Safety Committee (EHSSC) to oversee the conduct of activities related to use of hazardous materials.  The EHSSC assures that Temple University policies are consistent with protecting human health and the environment and comply with all applicable regulations. The EHSSC is chaired by a senior administrator and includes representatives of various schools and affiliated institutions.

The EHSSC meets as often as is necessary to ensure that the environmental health and safety program is operating in accordance with all regulatory requirements.  One half of the members, including the Director of EHRS, constitute a quorum.

The EHSSC is responsible for:

• Ensuring, with the assistance of the Director of EHRS, that the Environmental Health and Safety Program receives appropriate support and resources;
• Ensuring that all hazardous materials are used in compliance with all applicable regulatory requirements and institutional policies and procedures;
• Coordinating and managing  all activities that  may have an adverse impact on health and the environment if not properly administered;
• Ensuring that the use of hazardous material is consistent with the safety of humans and the environment;
• Reviewing and approving or disapproving, with the advice and consent of the Director of EHRS, all safety procedures and changes in the program;
• Identifying safety program problems and providing solutions to these problems;
• Periodically reviewing the summary report of Director of EHRS pertaining to inspection reports and recommending remedial action to correct any deficiencies identified in the safety program audits; and
• Taking all necessary steps to enforce compliance with local, state and federal regulations and with University policies and guidelines.

1.7 – Prohibition of Certain Activities in Laboratories

Recognizing that inhalation is not necessarily the only route of exposure to hazardous materials, regulatory agencies have promulgated regula­tions that prohibit activities that may lead to exposure to hazardous materi­als through the GI tract.  For the purpose of this policy, certain activities are prohibited in laboratories or similar facilities.

A laboratory or similar facility is an area where one or more of the following materials are used, handled or stored:

• Radionuclides
• Chemicals
• Biologic materials
• Cleaning agents, paints, solvents and similar chemicals
• Materials that, in the judgment of the Environmental Health and Radiation Safety Department, would pose an unreasonable health and safety risk.

The following activities are prohibited in laboratories or in similar facili­ties:

• Smoking
• Eating
• Drinking
• Application of cosmetics
• Manipulation of contact lenses
• Storage of foods and drinks

1.8 – Medical Assessment and Treatment

Risk management at Temple University is based on prevention of accidents and accidental exposure to hazardous material.  However, despite the best preventive measures, provisions must be made to manage accidents, including the treatment of those who have been overexposed to these agents. Occupational and Employee Health Services provide medical evaluation and support for exposure to hazardous material at Temple University Hospital.

Employees likely to be exposed to hazardous materials during the course of their work are provided with the opportunity to receive medical attention if warranted or needed. This includes medical consultation and follow-up, if warranted.

Any employee involved in an accident or with an injury that requires medical attention after hours should report to the Emergency Department.  During working hours, injured students should report to Student Health; after hours, they should report to the Emergency Department.

Employees likely to be exposed to bloodborne pathogens are encouraged to receive Hepatitis B vaccine. All incidental exposures involving bloodborne pathogens are evaluated and followed-up with medical attention, as necessary.

Baseline medical evaluation may be necessary as required by regulation, EHRS policy, or upon recommendation of appropriate committee(s).

1.9 – Guideline for Entering Hazardous Environments

The access to University premises, identified as laboratories, workshops, mechanical rooms, warehouses and other work areas housing potentially dangerous materials (chemical, biological, radiological, physical), conditions, machinery or processes, are limited to the authorized University staff and students or other persons on official or related business. 

Measures should be taken to ensure that persons entering into these areas are appropriately trained and adequately protected from hazards and are informed about the safety and emergency procedures relevant to their activities and presence. 

The entrance to these areas are prohibited for:

• Individuals who have not received safety training commensurate with the potential hazards present and are not under the direct and constant supervision of the laboratory director/supervisor.

• Individuals under the age of 18 unless special arrangements are made with EHRS and department chairperson, including training provided by the Environmental Health and Radiation Safety Department.

This guideline is intended to protect the health and well being of University employees and to avoid exposing unauthorized individuals to a hazardous environment.  Please contact EHRS at (215) 707-2520 if you have any questions.