Hazardous Materials Management

Introduction 1

General Procedures to Reduce Potential Hazards 2

Policy and Definition 3

Authority Accountability and Responsibility 7

Employee Rights 12

Material Safety Data Sheets (MSDS) 14

Labeling of Chemical Containers 16

Employee Training 17

Record Keeping 20

Procedure for Safe Laboratory Practices 22

Safe Storage and Disposal of Hazardous Materials 23

Appendix A - 26

Appendix A 29

Appendix B - Alara Program 30

Appendix C - Model Training Program 33

Appendix D - Model Rules for using Hazardous Materials 35

Appendix E - Model Spill Procedures 36

Appendix F - Model Procedures for Waste Disposal 38

Appendix F - Material Safety Data Sheet 39

Appendix H - Internal Forms 43

HAZARDOUS SUBSTANCE REPORT 43

EXPOSURE RECORD 44

REQUEST FOR CHEMICAL DISPOSAL 45

EMPLOYEE HAZARDOUS MATERIAL INFORMATION REQUEST 47

HAZARDOUS CHEMICAL INCIDENT REPORT 48

ACCIDENT REPORT FORM 49

Introduction

A hazardous chemical can be broadly defined as one with a potential danger to health or to the environment. Research laboratories are probably responsible for less than 1% of the hazardous chemical waste generated in our country. Nevertheless, we have a legal and moral obligation to use these substances in a manner that will cause the minimal potential harm. The laboratories at the New York State Psychiatric Institute (NYSPI) use hazardous materials. The objectives of this manual are to provide guidelines and regulations for the safe handling of toxic substances and procedures for other emergency situations. A program which focuses only on incident responses is unsatisfactory and shortsighted, because dangerous situations which may endanger personnel are better anticipated and controlled before an incident occurs. The program must be based on the anticipation of problems before an emergency occurs, with the major efforts directed towards reduction and prevention of accidents. We believe that the goals and objectives of this program extend above and beyond the legal regulations because we have a moral imperative to protect staff, patients and the environment from the hazards of toxic chemicals.

This manual establishes a Safety Program at the New York State Psychiatric Institute (NYSPI), which includes a Hazard Communication Standard (HCS) Program, and mechanisms used to order, identify, handle, and monitor hazardous chemicals and toxic substances are described. This program is consistent with and implements standards and recommendations for the "Right-to-Know Law," as defined in the OSHA Hazard Communication Standard (HCS) 29 CFR 1910 subpart 2 and the New York State Department of Labor Part 820, Toxic Substances Information, Training and Education, and Labor Law Article 28. The Radiation Safety Program is consistent with Article 175 Radiation Control of the New York City Health Code and the Radiation Safety Code of NYSPI.

This manual, which applies to all personnel at NYSPI, is an attempt to meet the particular safety requirements of NYSPI, including laboratory, clinical, support staff and patients. The complex mission of our Institute requires the use and handling of many varieties of hazardous substances with dangerous properties which require special precautions. As a result of this wide variety, safety depends on the awareness and training of all personnel. Individuals working with hazardous materials must be trained in their safe use and the use of Material Safety Data Sheets (MSDS). The professional expertise, common sense, judgment and training of laboratory worker, coordinators and the emergency response team serve as our first line of defense.

General Procedures to Reduce Potential Hazards

1 Prevent the accumulation of hazardous materials by disposing of old or unused chemicals, storing materials safely, reducing chemical inventories, ordering smaller quantities and substituting less hazardous materials when possible. Materials must be dated when received so that old, outdated and unused materials can be readily identified and discarded.

2 Train workers in safe laboratory procedures, such as the use of proper protective clothing and exposure prevention techniques to reduce risks. The use of MSDS's of specific materials will provide information on the proper methods for handling, disposal and emergency (spill) situations.

3 Decrease the amounts of chemicals on hand by using smaller sized containers and ordering smaller quantities.

4 Limit the amount of damage in an incident by providing an equipped and trained emergency response team.

5 Establish an ALARA program.

Policy and Definition

1 Purpose

A. To provide organizational and procedural guidelines for the facility director, medical and research staffs, and support and ancillary personnel.

B. To ensure the rights of all employees' to information, training and education regarding toxic and hazardous substances in the work place.

C. To provide guidelines for the safe handling of hazardous and toxic materials.

D. To provide guidelines for a trained and equipped emergency response team.

E. To provide guidelines for the safe storage and disposal of hazardous materials.

F. To provide guidelines for ordering hazardous materials.

2 Objectives

A. To ensure that a written safety program for hazardous and toxic materials is established.

B. To ensure that a written hazardous communication program is maintained.

C. To maintain a current inventory of all hazardous chemicals used and stored at NYSPI which is updated regularly.

D. To maintain and have available a Material Safety Data Sheet (MSDS) file on every substance on the inventory.

E. To ensure that all toxic and hazardous chemicals at NYSPI are properly labeled, stored and inventoried.

F. To provide training to all employees who work with or is potentially exposed to hazardous chemicals.

G. To advise outside contractors of any chemical hazards which may be encountered in the normal course of their work at NYSPI.

H. To provide guidelines for handling hazardous chemicals and toxic substances.

I. To provide guidelines for emergencies involving hazardous chemicals and toxic substances for personnel and an emergency response team.

3 Definition of Terms

A. "CHEMICAL" - means any element, chemical compound or mixture of elements and/or compounds.

B. "CONTAINER" - means any bag, barrel, bottle, box, can, cylinder, drum, reaction vessel, storage tank, or the like that contain a chemical.

C. "EMPLOYEE" - includes all regular and temporary, full-time and part-time employees, former employees employed after the effective date of Labor Law Article 28 (Dec. 80) and employees on lay-off and leaves of absence for any reason, who may be exposed to hazardous chemicals under normal operating conditions or foreseeable emergencies.

D. "EXPOSURE" or "EXPOSED" - means being subjected to a toxic substance through any actual or potential route of entry, including inhalation, ingestion, injection, skin contact or absorption, for any period of time, even if such exposure is accidental or if actual exposure is being prevented in whole or in part by the use of protective devices.

E. "HAZARD WARNING" - means any words, pictures, symbols, or combination thereof appearing on the label of a container or other appropriate form of warning which convey the hazards of the chemical(s) in the container(s).

F. "HAZARDOUS CHEMICAL" - means any chemical which is a physical hazard or a health hazard and requires special handling.

G. "HEALTH HAZARD" - means a substance for which there is statistically significant evidence that acute or chronic health effects may occur in exposed employees. The term "health hazard" includes chemicals which are carcinogens, toxic or highly toxic agents, reproductive toxins, irritants, corrosives, sensitizers, hepatotoxins, nephrotoxins, neurotoxins, agents which act on hematopoietic system, and agents which damage the lungs, skin, eyes, or mucous membranes.

H. "LABEL" - means any written, printed, or graphic material displayed on or affixed to containers of chemicals.

I. "MATERIAL SAFETY DATA SHEET (MSDS)" - means written material concerning a chemical which is prepared by the manufacturer or vendor in accordance with 29 CFR 1910.

J. "PHYSICAL HAZARD" - means a substance which is a combustible liquid, a compressed gas, explosive, flammable, an organic peroxide, an oxidizer, pyrophoric, unstable (reactive) or water-reactive.

K. "RADIOACTIVE AND IONIZING RADIATION" - means any of the following: alpha particles, beta particles, gamma rays, X-rays, neutrons, high speed electrons and protons and other atomic particles, but not sound, radio, or light waves.

L. "ROUTINE EXPOSURE" - means exposure which can be expected to occur in the course of employment as part of an employee's job duties or incidental thereto.

M. "TOXIC SUBSTANCE" - means any substance which is listed in the latest printed edition of the National Institute for Occupational Safety and Health registry of toxic effects of chemical substances or has yielded positive evidence of acute or chronic health hazards in human, animal or other biological testing.

N. "WORK AREA" - means a room,laboratory or defined space in a work place where hazardous chemicals are produced or used, and where employees are present.

O. "WORK PLACE" - means any location away from the home, permanent or temporary, where any employee performs and work-related duty in the course of his employment.

P. "IDENTITY" - means any chemical or common name which is indicated on the Material Safety Data Sheet (MSDS) for the chemical. The identity used shall permit cross-references to be made among the required list of hazardous chemicals, the label and the MSDS.

Q. "EMERGENCY RESPONSE TEAM" - a group of trained employees who respond to reports of major hazardous chemical spills and assist the coordinator, floor manager and chemical laboratory worker in cleanup and decontamination procedures. The team includes representatives from Safety, Housekeeping and Engineering and a Decontamination Team.

R. "STORAGE" - temporary placement of limited amounts of hazardous chemicals accompanied by MSDS, for temporary storage until removed by licensed vendor.

S. "CHEMICAL LABORATORY WORKER" - an individual trained to perform experiments and/or assays using hazardous materials in a laboratory.

T. "NON-LABORATORY WORKER" - is an individual not currently employed in a "chemical" laboratory who may be accidentally exposed to hazardous materials in the course of his duties.

U. "LABORATORY" - a generic term denoting a space wherein research or experimental work is conducted, except electronic, psychological or similar laboratories which use small quantities of chemicals for incidental purposes.

V. "STORAGE ROOM" - a room where toxic or hazardous chemicals are stored and not otherwise used.

W. "STORAGE CABINET" - a cabinet in laboratory or storage room for the storage of not more than 60 gallons of flammable liquid and constructed in accordance with OSHA standards.

X. "TRAINING" - The education and training program which meets the requirements listed in Part 820 for substantive information.

Authority Accountability and Responsibility

1 THE FACILITY DIRECTOR (FD)

A. Has the ultimate responsibility for the hazardous substance program at the NYSPI.

B. Ensures implementation and enforcement of this program in accordance with OSHA's (Federal) and New York State directives.

C. Designates, in writing, individuals to serve as the program coordinator and departmental managers.

2 THE EXECUTIVE COMMITTEE (EC)

A. Enforces the policies and procedures of the program and ensures compliance by all departments and sections.

B. Receives, reviews and acts upon reports and recommendations of the Safety Committee and Coordinator.

C. Advises the staff on program policies.

D. Monitors compliance with OSHA Hazard Communication Standard and N.Y.S. "Right-To-Know-Law" and all aspects of the program with the Safety Committee and Coordinator.

3 THE SAFETY COMMITTEE (SC)

A. Appoints a Hazardous Chemical Committee to develop additional programs.

B. Coordinates all program activities with the Facility Director, Executive Committee, Hazardous Chemical Committee and the Safety Committee.

4 THE HAZARDOUS MATERIALS COMMITTEE (HMC)

A. Oversees the organization and effectiveness of individual departments and services and ensures that instructions and program are established and appropriately fulfilled.

B. Serves as the centralized collection and evaluation body for all information pertaining to hazardous and toxic materials at NYSPI.

C. Monitors all problems as necessary to assure continued resolution.

5. THE SAFETY COORDINATOR (SC)

A. Serves as the communication and coordination link between various department managers, the Safety Committee and the Hazardous Materials Committee.

B. Maintains the inventory of all hazardous chemicals and toxic substances used at NYSPI, updating as necessary.

C. Maintains a MSDS file on every substance on the hazardous chemical inventory currently or in the past. Reviews each MSDS for accuracy and completeness as far as possible.

D. Ensures that all hazardous chemicals in the facility are properly labeled.

E. Advises outside contractors of any chemical hazards which may be encountered in the normal course of their work at NYSPI.

F. Obtains and files MSDS's from outside contractors for hazardous or toxic materials that are brought into NYSPI.

G. Reviews and coordinates inputs from a variety of sources to identify real or potential chemical safety problems and informs the Safety Committee as appropriate.

H. Maintains records of the name, address and social security number of every employee who handles or uses toxic substances listed in 29 CFR 1910 Subpart Z. (Such records shall be kept for forty years.)

I. Reports to the facility director on current chemical safety activities including problems and actions taken.

J. Reviews all activities of the program and inspects the facility annually. Reports results to the Safety Committee.

K. Assists department managers in education programs for employees on the right to know and safety programs, health hazards and protective measures.

L. Assists HCS managers in obtaining appropriate labels for containers and MSDS's.

M. Ensures that the Emergency Response Team is equipped and trained.

N. Directs the Emergency Response Team during decontamination procedures.

O. Reports incidents to the Safety Committee the Hazardous Chemical Committee.

6 RADIATION SAFETY OFFICER (RSO)

A. Administers the radiation safety program described in Article 175 NYC Health Code and Radiation Safety Code of NYSPI.

B. Maintains a record of current (and past) inventories of all radioactive material at NYSPI.

C. Maintains a record of exposure of all NYSPI personnel authorized to use penetrating radiation.

D. Works under the direction of the Radiation Safety Committee.

E. Sits on the Safety Committee and Hazardous Materials Committee.

7 DEPARTMENT MANAGERS

A. Administer the hazardous and toxic chemical safety program for the department and laboratories.

B. Maintain current inventory of chemicals/substances used in the work area.

C. Acquire and file MSDS for newly acquired chemical substances. Send copy to coordinator.

D. Ensure MSDS file of hazardous materials used in work area is readily accessible to all employees.

E. Ensure all hazardous materials in work area are properly labeled.

F. Inspect containers on a regular basis to ensure containers are labeled and that labels are up to date.

G. Completes a monthly report which is submitted to the Coordinator by the 10th of each month. (See Attachment I)

H. Provide training (with the program Coordinator) to employees who work with or are potentially exposed to hazardous chemicals. (See chapter 6).

I. Post signs in work area informing employees of their right to information under Right to Know law.

J. Upon written request by an employee, provide information on hazardous and toxic substances as outlined in Chapter 7. Request forms must be available to employees.

K. Maintain a current copy of this manual for the department.

L. Acts as first line of defense after a spill. Reports spill and calls in alarm to Emergency Response Team and the Safety Coordinator, identifies chemical, amount spilled and provides MSDS.

M. Directs primary response, i.e., evacuation of personnel and sealing room.

N. Acts with Coordinator and Emergency Response Team to contain, control and eliminate spill.

8 LABORATORY WORKERS

A. Are entitled to and require training in the use and handling of chemicals in the workplace.

B. Have the primary responsibility for the safe handling of harmful substances at NYSPI.

C. Must be familiar with the MSDS's of substances commonly used in the laboratory including necessary precautions in use and decontamination and safety procedures in case of a spill.

D. Must inform the Department Manager and/or Safety Department in case of a spill, including substance, amount, building and room location.

E. Work with Emergency Response Team during spill cleanups.

9 EMERGENCY RESPONSE TEAM

A. Coordinator has overall responsibility for spill decontamination with Department Manager.

B. Laboratory workers will assist in the cleanup.

C. Safety Department report to area with crash cart, secure it, and if necessary, assist in evacuation.

D. Engineering Department will send a supervisor with information on utilities and other systems.

E. Housekeeping personnel will complete cleanup after decontamination is completed.

F. Decontamination Team will assist in the containment and cleanup of the spill.

10 DECONTAMINATION TEAM

A. A group of employees with training in handling and responding to emergencies involving spills of hazardous chemicals.

B. Training will be provided in the following areas:

1. Reading and interpreting MSDS.

2. Handling volatile flammable solvents.

3. Handling corrosive chemicals.

4. Handling toxic materials.

5. Use of protective clothing.

6. Fire and injury prevention.

Employee Rights

1 RIGHT-TO-KNOW

a. Signs must be posted informing employees that they have a right to information regarding:

(1) The toxic substances found in their work place,

(2) Toxic effects of these substances,

(3) The circumstances under which these toxic effects are produced.

b. When an employee requests the above information, it must be made available to the employee and/or their representatives in a comprehensible manner within a reasonable amount of time as prescribed by law.

2 INFORMATION PROVIDED INCLUDES:

a. A copy of the MSDS of the substance. This material will be explained (and translated) if necessary.

b. Information about any toxic substance known to be present in a mixture even if present only in trace amounts.

c. New information about any toxic substance.

d. The existence, requirements and details of this program.

e. Operations involving hazardous chemicals or procedures.

3 PROCEDURE TO REQUEST INFORMATION (MSDS):

a. Employees must make a written request for information relating to toxic substances they may encounter at NYSPI.

b. Employers must provide requested information (MSDS) within seventy-two hours or (three work days).

c. If the requested information is not provided within the time limits, the employee is not required to work with the substance.

d. No employee may be disciplined or discharged for filing a complaint or instituting any proceeding relating to this standard.

e. Supervisors or staff will forward copies of the written requests for information to the Safety Coordinator for recording.

4 ADDITIONAL REQUIREMENTS:

a. An education and training program for employees who may be exposed to toxic substances at NYSPI will occur each year.

b. Employees will be informed of chemical hazards and the required protective measures prior to using hazardous and toxic substances.

c. Individuals who work with or are exposed to hazardous materials will be given copies of the MSDS to read. They will be required to sign a roster that they have read the MSDS. The Safety Coordinator and Department Manager are responsible for providing the MSDS to the staff.

d. Contractors who may be exposed to hazardous chemicals at NYSPI must be informed verbally and in writing of any hazards before commencing work the SC.

e. Contractors who use any chemicals at NYSPI must provide a MSDS to the SC for each substance used prior to the start of work.

Material Safety Data Sheets (MSDS)

1. The Safety Coordinator will maintain an MSDS file of all chemicals used at NYSPI.

a. The MSDS will consist of a fully completed OSHA Form 174 or equivalent.

b. Each MSDS will be reviewed for accuracy and completeness.

c. All MSDS of toxic substances used at NYSPI since June 1, 1987 will remain on file.

2. The Department Managers shall maintain a file of MSDS's for chemicals in their work areas.

a. They are responsible for acquiring and updating MSDS's.

b. They must ensure MSDS's are readily available to their staff and the coordinator.

c. They must obtain MSDS upon receipt of the first shipment or prior to use of any potentially hazardous chemical purchased. Vendors must provide MSDS in a timely manner, or payment will be delayed until MSDS is received.

3. MSDSs are not required for chemicals in small special containers (such as spray cans), which are obtained from general retail stores where MSDS's are unavailable.

4. Required contents of a Material Safety Data Sheet (See example)

a. Identity of the chemical or product used on the label.

b. The chemical and common name of the substance.

c. The chemical and common name of hazardous ingredients.

d. Physical and chemical characteristics.

e. The physical hazards, including the potential for fire, explosion and reactivity.

f. The health hazards, including signs and symptoms of exposure.

g. The primary routes of entry.

h. The OSHA Permissible Exposure Limit (PEL) or ACGIH recommended Threshold Limit Value (TLV).

i. If the substance is described as a carcinogen by the National Toxicology Program of International Agency for Research on Cancer or by OSHA.

j. Instructions for safe handling and use.

k. Generally applicable control measures including appropriate engineering controls and personal protective equipment.

l. Emergency and first aid procedures.

m. Date of preparation of the MSDS or date of the most recent revision or update.

n. Name, address and telephone number of the chemical manufacturer.

5. Purchasing Departments must request an MSDS for all substances ordered. An order file will be kept for the Safety Coordinator so that new items may be identified, tracked and MSDS's filed.

6. Central Receiving will forward any MSDS's to the Safety Coordinator.

7. MSDS must be made available to the cleanup and decontamination teams as soon as possible.

Labeling of Chemical Containers

1 All chemical containers used at NYSPI must be properly labeled with the following information:

a. The identity of the chemical in the container. The name must be consistent with the MSDS and chemical list.

b. Appropriate hazard warning such as flammable - poison - oxidizer, etc.

c. The date received and the name of the department must be added to label.

2 All labels must be legible and prominently displayed.

3 Temporary containers into which hazardous chemicals are transferred from labeled containers, and which are intended only for the immediate use (same shift) of the employee who performs the transfer, are not required to be labeled as above but must have the name of the substance on the container.

4 Existing labels on incoming containers of hazardous chemicals shall not be removed or defaced.

5 Containers of hazardous chemicals will be inspected by the department managers at least every three months to ensure compliance. A report of this inspection will be sent to the Safety Coordinator.

6 Labels may be obtained or ordered through the Safety Coordinator.

7 Unlabeled containers will not be accepted for storage or disposal.

Employee Training

1 All employees of NYSPI will receive Hazardous Communication Standards training on an initial and on-going basis. (Appendix C)

2 The Department of Education and Training will provide an initial introduction to the Safety Program during the employee's orientation which usually occurs on the first day of employment. This training will:

a. Inform employees of their Right-to-Know rights about the health effects of any substance present at their work site.

b. Inform employees of the Hazardous Communication Program and Safety Program at NYSPI.

c. Inform employees of the role of the Safety Department, the Safety Coordinator and Departmental Managers.

d. Provide access to a copy of this manual and appropriate forms.

3 The Safety Department (and Safety Coordinator) will discuss the Hazardous Materials Safety Program during the New Employee Orientation program. This training will:

a. Summarize the program.

b. Instruct employees on how to obtain and use Material Safety Data Sheets (MSDS).

c. Instruct employees on reading labels on containers.

d. Instruct employees on hazardous chemical properties, visual appearance and odor and methods used to detect the presence of hazardous materials.

e. Instruct employees on safe work practices including personal protective equipment and emergency procedures.

f. Instruct employees on general procedures for handling hazardous chemical spills and leaks.

4 The Department Safety Manager will provide training on the safe use of hazardous chemicals which will be encountered by the employee during the employee's initial orientation. In addition, the manager will:

a. Inform the new employee of the location of the MSDS file.

b. Inform the employee of the physical and health hazards associated with potential exposure to work area chemicals.

c. Instruct employees on the hazardous chemical properties, including appearance and odor of hazardous chemicals found in work area.

d. Instruct the employee on specific protective procedures for work area hazards, including the use of personal protective equipment, safe work practices and emergency procedures.

e. Instruct employees on the response during hazardous chemical spills and leaks.

5 All employees must attend an annual safety training session.

6 The Safety Department and Safety Coordinator with the Safety Committee is responsible for an annual safety training program which will:

a. Review the major provisions of the HM program.

b. Review how to obtain and use MSDS.

c. Review hazardous chemical properties.

d. Review general safety procedures.

e. Review emergency procedures used during hazardous chemical spills and leaks.

7 The Department Safety Manager will review and update the safe use of hazardous chemicals in the departmental work area as necessary.

a. Review the location of MSDS files in the work area.

b. Review the hazards associated with exposure to work area chemicals.

c. Review work area-specific hazardous chemical properties and detection procedures.

d. Review specific procedures for protection against hazards in the work area.

e. Review specific emergency procedures for hazardous chemical spills and leaks.

8 The Department Safety Manager will provide training on the safe use of new hazardous chemicals in the employee's work area. This training will be provided before employees are required to work with the new chemical.

9 Training will be provided during regular working hours in a convenient work location.

10 Training of work area Departmental Safety Managers will be provided by the Safety Coordinator in conjunction with the Department of Education and Training.

11 All training will be documented in accordance with existing Department of Education and Training policies and procedures.

12 Records of the training of each employee will be maintained by the Department of Education and Training, and reports must be submitted to the Safety Department, Safety Coordinator, and Department of Quality Assurance for monitoring.

Record Keeping

1 The Safety Department will maintain employee records for forty years if such employee has been exposed to any toxic substances listed in 29 CFR 1910 Subpart 2. The exposure records will specify the name, address and social security number of the employee and the chemical and trade name(s) chemical abstracts, service number, and chemical manufacturer, if known.

a. The Personnel Department will keep records for each employee for the required amount of time. The records will contain the employee's name, social security number, address, dates and department(s) of employed in at NYSPI.

b. A list of the potential exposures of each employee to substances on the 29 CFR 1910 Subpart 2 listing will be maintained by the Safety Department. A copy of this list will be produced on demand.

c. An exposure record (See Attachment) will be completed by the Department managers to document spills involving employees. Copies of these reports will be sent to the Personnel Department to keep on the left side of the employee's personnel record. Upon termination, the exposure record will be sent to the Safety Department for filing.

d. The individuals records must be made available to affected employees, former employees, designated physician, or representative of the Commissioner of Health upon request.

2 The Safety Committee will maintain a file of materials required to comply with regulations including training materials and the MSDS's for each toxic substance in the work place after June I, 1987.

3 Individual training records will be maintained by the Department of Education and Training.

4 Written requests for information by employees will be kept on file by the Safety Department.

5 The Safety Coordinator will keep the Chemical Inventory list up to date by reviewing the monthly reports submitted by the Departmental managers.

6 Each Department Manager at NYSPI will maintain a Safety Manual. The Safety Manual will be in a binder, accessible to employees and kept current. It will contain Safety Policies for NYSPI, departmental inventory and alphabetical MSDS file.

Procedure for Safe Laboratory Practices

1 It is almost impossible to design a set of rules of reasonable size that will cover all possible hazards and occurrences. The most important part of every safety program is safety training and awareness of all personnel. These guidelines are from "PRUDENT PRACTICES FOR HANDLING HAZARDOUS CHEMICALS IN LABORATORIES" and can be modified for particular needs.

A. Laboratory Supervisors have overall safety responsibility and should ensure that all laboratory workers are trained in safety procedures.

B. Protective equipment must be worn when necessary.

C. Safe work habits must be developed such as use of pipet bulb for pipettery and washing of hands.

D. A clean uncluttered work area should be provided, spills cleaned immediately and all chemical containers labeled.

E. Access to all exists should be kept clear.

F. Sprinklers, Eye wash stations, fire extinguishers, fire blankets, showers, chemical waste containers should be available and checked at regular monthly intervals.

G. Proper signs posted.

H. All laboratory accidents and spills must be reported.

I. No preparation and consumption of food or beverages in laboratories.

J. Use of fume hood when necessary.

Safe Storage and Disposal of Hazardous Materials

1 OBJECTIVES

A. To develop procedures to store and/or dispose of excess or outdated hazardous chemicals and chemical waste in a manner that will subject personnel and the environment to minimal harm and danger. Hazardous chemicals have been defined by the National Fire Protection Association (NFPA) in their hazard identification system. For the purpose of this report we will use the following hazard categories: (the higher the number the greater the hazard).

1. Health (1) dangerous in case of fire and (2), (3), (4) which includes toxins, venoms, and carcinogens, but not radioactive materials.

2. Flammability (3) and (4) which include flammable gasses, very volatile liquids and liquid and solids with low flash points.

3. Reactivity (2), (3), and (4) which include explosives and materials which undergo violent chemical change.

2 STORAGE FACILITY

A. The storage facility is located on the 19th floor and meets New York City Fire Department specifications for holding excess material prior to use and disposal. Space, in fire proof cabinets, is limited and can be obtained on a space available basis.

B. REGULATIONS FOR STORAGE OF EXCESS QUANTITIES CHEMICAL

1. Access to the storage facility will be regularly scheduled on the 1st and 3rd Tuesdays of each month. In emergencies call Chief Willie Herriott (extension 2210) or Dr. Morton Levitt (extension 5847).

2. Storage requires prior approval, available cabinet space and delivery to facility.

3. Prior to transport to the storage facility all containers must be legibly marked with the contents and the department name and the date. Unlabeled material is not acceptable.

4. All material must be packed for transport either in the original shipping containers or safety containers.

5. A cart must be used to transport more than one container.

6. Hazardous materials will be transported on the high rise elevator which will be taken from service for this purpose. The elevator will be available on request between the hours of 10 a.m. to 11:30 a.m. and 1:30 p.m. to 4:00 p.m.

7. Inventories of materials in the storage facility must be maintained by the department, and a copy given to Chief Herriott.

8. Cabinets will be checked quarterly to dispose of unwanted and outdated chemicals by the department and by the Safety Committee.

9. The purpose of the facility is for temporary storage of hazardous materials. The disposition of materials stored for more than 2 years will be reviewed.

C. REGULATIONS FOR THE DISPOSAL OF HAZARDOUS MATERIALS

1. A hazardous material has one or more of the following NFPA ratings.

Health 2, 3, 4

Flammability 3, 4

Reactivity 2, 3, 4

2. Material will be taken to the 19th floor facility only on the 1st and 3rd Tuesdays of each month.

3. Prior to pickup, all hazardous material must be inventoried on the form provided (attachments) which must be completely filled out.

4. All material must be packed and prepared for safe transport.

5. All material will be transported in a safe manner.

6. Charges for disposal will be based on the size and number of containers.

7. Efforts must be made to identify materials because unknown substances can not be accepted because they are not picked up by the vendor.

8. All containers must have a single label which describes contents, department and date.

9. Toxins, venoms, carcinogens, and similar compounds will be removed only after discussion with laboratory manager or responsible investigator as to the proper procedures for safe handling and disposal.

10. Hazardous waste will be removed by a licensed vendor ONLY.

D. REGULATIONS FOR ORDERING HAZARDOUS MATERIALS

1. Orders of hazardous materials should be kept to minimum quantities because storage and disposal is time consuming and expensive. A 3 to 6 month inventory should be the maximum amount kept on hand.

2. Purchase requests for hazardous materials must indicate that a hazardous substance is ordered and the degree of hazard of the material.

3. Researchers who order toxins, venoms, carcinogens, must indicate, in writing, that they are familiar with the use, storage, necessary precautions, and disposal of the material.

4. The storeroom will accept shipments of hazardous material and keep them in a safe place, in the original shipping containers for as short a period of time as possible.

5. Hazardous materials will be delivered to the laboratories in the original shipping containers at off peak hours.

6. As an alternative to large orders of hazardous materials, open orders can be placed to allow for direct ordering of smaller quantities on an as-needed basis. This procedure will markedly reduce our inventory of hazardous materials.

Appendix A - New York State Psychiatric Institute Hazardous Material Charter

CHARTER: NEW YORK STATE PSYCHIATRIC INSTITUTE HAZARDOUS MATERIAL

1 COMMITTEE

A. Mr. Steven M. Papp, Chairman (Management)

B. Mr. Harold Seligson, Co-Chairman

C. Dr. Ray Holodney, Columbia University R.S.O.

D. Ms. Renee Doolity, R.N.

E. Mr. David Pierson

F. Chairman, Infection Control Committee

G. Mr. Willie Herriott, Chief Safety Officer

H. Mr. Peter Reynolds, Plant Superintendent

I. Adjunct Members as needed

2 CHARGE: The Committee shall:

A. Ensure that hazardous material will be used safely. This includes review as necessary of training programs, equipment, facility, supplies, and procedures;

B. Ensure that hazardous material is used in compliance with applicable regulations.

C. Ensure that the use of hazardous material is consistent with the ALARA philosophy and program;

D. Identify program problems and solutions.

E. Implement an ALARA Program.

3 RESPONSIBILITIES: The Committee shall:

A. Be familiar with and have copies of all pertinent regulations, license, and amendments;

B. Prescribe special conditions that will be required during a proposed method of use of hazardous material such as requirements for bioassays, physical examinations of users, and special monitoring procedures;

C. Establish a training program to ensure that all persons whose duties may require them to work in or frequent areas where or adjacent to hazardous materials are used are appropriately instructed.

D. Review at least the entire hazardous materials safety program to determine that all activities are being conducted safely, in accordance with regulations and the conditions of the license, and consistent with the ALARA program and philosophy. The review must include an examination of records, safety procedures, and the adequacy of the management control system;

E. Recommend remedial action to correct any deficiencies identified in the hazardous materials safety program;

F. Maintain written minutes of all Committee meetings, including members in attendance and members absent, discussions, actions, recommendations, decisions, and numerical results of all votes taken;

G. Meet at least once a year.

4 ADMINISTRATIVE INFORMATION

A. The Committee shall meet as often as necessary to conduct its business but not less than once in each calendar year.

B. Membership must include the authorized Safety Coordinator, a representative of the nursing service, and a representative of management who is neither an authorized user nor the Safety Coordinator. Management may appoint alternate members to participate in meetings in the case of absence of principal members and will appoint adjunct members from security, physical plant, housekeeping, or other departments.

C. To establish a quorum, one-half of the Committee's membership, including the HMSO and the management representative, must be present.

5 REVIEW OF ALARA PROGRAM

A. The HMSC will encourage all users to review current procedures and develop new procedures as appropriate to implement the ALARA concept.

B. The HMSC will perform a quarterly review of occupational hazardous material exposure. The principal purpose of this review is to assess trends in occupational exposure as an index of the ALARA program quality and to decide if action is warranted when investigational levels are exceeded.

C. The Committee will evaluate our institution's overall effort for maintaining doses of ALARA on an annual basis. This review will include the efforts of the authorized users and workers, as well as those of management.

6 ANNUAL REVIEWS

A. Annual review of the radiation safety program. The HMC will perform an annual review of the program for adherence to ALARA concepts. Reviews of specific methods of use may be conducted on a more frequent basis.

B. Review of occupational exposures. The HMC will review the exposure of authorized users and workers to determine that their doses are ALARA.

C. Annual review of records. The HMC will review surveys in unrestricted and restricted areas to determine that dose rates and amounts of contamination were at ALARA levels during the previous quarter.

7 EDUCATION RESPONSIBILITIES FOR ALARA PROGRAM

A. The HMC will schedule briefings and educational sessions to inform all workers of ALARA program efforts.

B. The HMC will ensure that authorized users, workers, and ancillary personnel who may be exposed will be instructed in the ALARA philosophy and informed that management and the HMC, are committed to implementing the ALARA concept.

Appendix A

MEMO TO: All Employee DATE

FROM: Mr. Steven M. Papp

Deputy Director for Administration

SUBJECT: DELEGATI0N OF AUTHORITY

-----------------------------------------------------------------------------------------------------------------------------------------------------

_______________________ has been appointed Safety Coordinator, and is responsible for ensuring the safe use of hazardous material. The Safety Coordinator is responsible for managing the safety program; identifying safety problems; initiating, recommending, or providing corrective actions; verifying implementation of corrective actions; and ensuring compliance with regulations. The Officer is hereby delegated the authority necessary to meet those responsibilities.

The Officer is also responsible for assisting the Hazardous Material Safety Committee in the performance of its duties and serving as its secretary.

Appendix B - Alara Program

1 MANAGEMENT COMMITMENT

A. We, the management of this research facility, are committed to keeping individual and collective exposure as low as is reasonably achievable (ALARA). In accord with this commitment, we hereby describe an administrative organization for hazardous material safety and will develop the necessary written policy, procedures, and instructions to foster the ALARA concept within our institution. The organization will include the Safety Committee, the Hazardous Material Committee (HMSC), the Safety Coordinator and the Radiation Safety Officer (RS0) or representative.

B. We will require a formal annual review of the safety program which will include reviews of operating procedures and past exposure records, inspections, etc., and consultations with the staff or outside consultants.

C. Modifications to operating and maintenance procedures and to equipment and facilities will be made if they will reduce exposures unless the cost, in our judgment, is considered to be unjustified. We will be able to demonstrate, if necessary, that improvements have been sought, that modifications have been considered, and that they have been implemented when reasonable. If modifications have been recommended but not implemented, we will be prepared to describe the reasons for not implementing them.

D. In addition to maintaining exposure to individuals as far below the limits as is reasonable achievable, the sum of the exposure received by all exposed individuals will also be maintained at the lowest practicable level. It would not be desirable, for example, to hold the highest doses to individuals to some fraction of the applicable limit if this involved exposing additional people.

2 HAZARDOUS MATERIAL COMMITTEE (HMC)

A. Delegation of Authority

The Judicious delegation of the Safety Committee and HMC authority is essential to the enforcement of an ALARA program.

1. The HMC will delegate authority to the Safety Coordinator for enforcement of the ALARA concept.

B. Review of ALARA Program

1. The HMC will encourage all users to review current procedures and develop new procedures as appropriate to implement the ALARA concept.

2. The HMC will review exposure. The principal purpose of this review is to assess trends in occupational exposure as an index of the ALARA program quality and to decide action is warranted when investigational levels are exceeded.

3. The HMC will evaluate our institution's overall effort for maintaining the ALARA program on an annual basis. This review will include the efforts of the Safety Coordinator, authorized users, and workers as well as those of management.

C. Cooperative Efforts for Development of ALARA Procedures

All workers will be given opportunities to participate in formulating the procedures that they will be required to follow.

1. The HMC or its representative the Safety Committee will be in close contact with all users and workers in order to develop ALARA procedures for working with radioactive materials.

2. The HMC will establish procedures for receiving and evaluating suggestions of individual workers for improving health physics practices and will encourage the use of those procedures.

D. Reviewing Instances of Deviation from Good ALARA Practices

The HMC will investigate all known instances of deviation from good ALARA practices and, if possible, will determine the causes. When the cause is known, the HMC will implement changes in the program to maintain doses ALARA.

3 INDIVIDUALS WHO RECEIVE OCCUPATIONAL EXPOSURE

A. Workers will be instructed in the ALARA concept and its relations, work procedures and work conditions.

B. Workers will be instructed in recourses available if they feel ALARA is not being promoted on the Job.

7. SIGNATURE OF CERTIFYING *OFFICIAL

I hereby certify that this institution has implemented the Program set forth above.

__________________________________________

Signature

__________________________________________

Name (print or type)

__________________________________________

Title

* The person who is authorized to make commitments for the administration of the Institution (e.g., hospital administrator)

Appendix C - Model Training Program

A. It may not be assumed that safety instruction has been adequately covered by prior occupational training. Site-specific training should be provided for all workers. Ancillary personnel (e.g., nursing, clerical, housekeeping, security) whose duties may require them to work in the vicinity of hazardous material (whether escorted or not) need to be informed about the hazards and appropriate precautions. All training should be tailored to meet the needs of the individuals in attendance. A training program that provides necessary instruction should be written and implemented.

B. MODEL PROGRAM

Personnel will be instructed:

1. Before assuming duties with, or in the vicinity of, hazardous materials.

2. During annual refresher training.

3. Whenever there is a significant change in duties, regulations, or the terms of the license.

C. INSTRUCTION FOR INDIVIDUALS IN ATTENDANCE WILL INCLUDE THE FOLLOWING SUBJECTS:

1. Applicable regulations.

2. Areas where hazardous material is used or stored.

3. Potential hazards in each area where the employees will work.

4. Appropriate safety procedures.

5. Licensee's in-house work rules.

6. Each individual's obligation to report unsafe conditions to the Hazardous Material Safety 0fficer or the Safety Committee.

7. Worker's right to be informed of occupational exposure and bioassay results.

8. Locations where copies of pertinent regulations and conditions as required by "Right-to-Know Laws."

9. Question and answer period.

10. Reading and interpreting MSDS.

Appendix D - Model Rules for using Hazardous Materials

1. Wear laboratory coats or other protective clothing at all times in areas where hazardous materials are used.

2. Wear disposable gloves at all times while handling hazardous materials, changing them frequently.

3. Either after each procedure or before leaving the area, monitor your hands for contamination.

4. Do not eat, drink, smoke, or apply cosmetics in any area where hazardous material is stored or used.

5. Do not store food, drink, or personal effects in areas where hazardous material is stored or used.

6. Dispose of hazardous waste only in designated, labeled receptacles.

7. Never pipette hazardous materials by mouth.

8. Wash hands after completing procedure.

Appendix E - Model Spill Procedures

1 MINOR SPILLS OF LIQUIDS AND SOLIDS

A. Notify persons in the area that a spill has occurred.

B. Prevent the spread of contamination by covering the spill with absorbent paper.

C. Clean up the spill using disposable gloves and absorbent paper. Carefully fold the absorbent paper with the clean side out and place in a plastic bag for transfer to a hazardous material container. Also put contaminated gloves and any other contaminated disposable material in the bag.

D. Check the area around the spill. Also check your hands, clothing, and shoes for contamination.

E. Report the incident to the Safety Coordinator (SC) and Safety Committee. Call Ext. 333 in an emergency.

F. The Safety Officer will follow up on the cleanup of the spill and will complete the Spill Report.

2 MAJOR SPILLS OF LIQUIDS AND SOLIDS

A. Clear the area. Notify all persons not involved in the spill to vacate the room. CALL EXT. 333

B. Prevent the spread of contamination by covering the spill with absorbent paper, but do not attempt to clean it up. To prevent the spread of contamination, limit the movement of all personnel who may be contaminated.

C. Close the room and lock or otherwise secure the area to prevent entry.

D. Notify the Safety Office immediately.

E. Decontaminate personnel by removing contaminated clothing and flushing contaminated skin with lukewarm water and then washing with mild soap. If contamination remains, induce perspiration by covering the area with plastic. Then wash the affected area again to remove any contamination that was released by perspiration.

F. The Safety Coordinator will supervise the cleanup of the spill and will complete the Spill Report Survey.

3 MAJOR SPILLS AND MINOR SPILLS

A. The decision to implement a major spill procedure instead of a minor spill procedure depends on many incident-specific variables such as the number of individuals affected, other hazards present, likelihood of spread of contamination, and types of surfaces contaminated as well as the toxicity of the spilled material.

4 SPILL KIT FOR EACH LABORATORY FLOOR

A. You may also want to consider assembling a spill kit that contains:

1. 6 pairs disposable gloves

2. 1 pair housekeeping gloves

3. 2 disposable lab coats

4. 2 paper hats

5. 2 pairs shoe covers

6. 1 "squeegee-type" mop

7. 1 roll absorbent paper with plastic backing

8. Absorbent Paps

9. Sodium Bicarbonate

10. 6 plastic trash bags with twist ties

11. "Hazardous Material" labeling tape

12. 1 china pencil or marking pen

13. 3 prestrung "Hazardous Material" labeling tags

14. Supplies for 10 contamination wipe samples

15. Instructions for "Emergency Procedures"

16. Clipboard with one copy of Spill Report Form

17. Pencil

Appendix F - Model Procedures for Waste Disposal

1 OVERVIEW

A. There are three commonly used methods of waste disposal: release to the environment through the sanitary sewer or by evaporative release; transfer to a burial site or back to the manufacturer; and release to in-house waste.

2 GENERAL GUIDANCE

A. All hazardous material labels must be defaced or removed from containers and packages prior to disposal. If waste is compacted, all labels that are visible in the compacted mass must be defaced or removed.

B. Remind employees that non-hazardous waste such as leftover reagents, boxes, and packing material should not be mixed with hazardous waste.

C. Review all new procedures to ensure that waste is handled in a manner consistent with established procedures.

D. In all cases, consider the entire impact of various available disposal routes. Consider occupational and public exposure to hazards associated with the material and routes of disposal (e.g. toxicity, carcinogenicity, pathogenicity, flammability), and expense.

3 MODEL PROCEDURE FOR DISPOSAL OF LIQUID AND GASES

A. Liquids may be disposed of by release to the sanitary sewer or evaporative release to the atmosphere. This does not relieve licensees from complying with other regulations regarding toxic or hazardous properties of these materials.

Appendix F - Material Safety Data Sheet

Appendix F - Material Safety Data Sheet

Appendix F - Material Safety Data Sheet

Appendix F - Material Safety Data Sheet

Appendix H - Internal Forms

TO: HAZARDOUS CHEMICAL COORDINATOR DATE:

MAILBOX 31

FROM:

===============================================

1. HAZARDOUS CHEMICALS DURING _______________ WERE:

_____Added _____Deleted _____No Change

Remarks: (Name of item, pertinent information, date)

2. MSDSs

_____An MSDS was obtained from manufacturer for each new item. A copy is attached.

_____ An MSDS was not received from manufacturer for new item.

An MSDS was requested on __________________ from:

_____ Not Applicable

3. An inspection of all hazardous containers and labels was completed on ________ and:

________ No discrepancies were found. Labels are in compliance with HCS

guidelines.

_______ The following discrepancies were found:

Action Taken:

4. TRAINING:

Employees were trained for use of new chemical.

________ Initial training was completed for new employees.

________ Training List(s) was sent to Education Office.

________ Not Applicable.

NAME OF EMPLOYEE INVOLVED:

_______________________________________________________SOCIAL SECURITY NUMBER:______________________________________________________________

DATE:_____________________________________________________________

LOCATION-/-BUILDING_________________FLOOR_________ROOM__________________

NAME OF CHEMICAL:

______________________________________________________________________________

QUANTITY:___________________________________________________________________

PROCEDURE USED FOR CLEANUP:

_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________EMPLOYEE TREATMENT:________________________________________________________________

THIS FORM IS TO BE SENT TO THE SAFETY OFFICE FOR REFERENCE.

* If an employee requires medical treatment Form 83ADM (MH) 4/78 must be included. Copies of this form Report of Accident Investigations enclose.

cc: Safety Department

Hazardous Chemical Coordinator

Safety Committee

Hazardous Chemicals Committee

Personnel

TO: HAZARDOUS CHEMICAL COORDINATOR - MAILBOX 31

===============================================

CONTAINER NFPA HAZARD SPECIAL

COMPOUND SIZE & NO. HEALTH FLAM REACT OTHER CONDITIONS

===============================================

______________________________________________________________________________

______________________________________________________________________________

____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

===============================================

UNKNOWN/UNLABELED MATERIAL(S) WILL NOT BE ACCEPTED!

DATE:_______________________________

PACKAGING:_______________________________________COST:_____________________

LOCATION (Building, Floor, Room No.):_________________________________________

DEPARTMENT:___________________________________________________________

DEPARTMENT HEAD:__________________________________________________

CONTACT PERSON:________________________________ TELEPHONE EXT.: ________

SAFETY COMMITTEE:_________________________________________________

SAFETY COORDINATOR: ____________________________________________________

TO: HAZARDOUS CHEMICAL COORDINATOR - MAILBOX 31

FROM: __________________________________________________________________

DATE: ______________________________ TELEPHONE: ______________________

BUILDING/ROOM LOCATION: ___________________________________________

DEPARTMENT: __________________________________________________________

SUPERVISOR: __________________________________________________________

NAME OF SUBSTANCE(S):

[1] ____________________________________________________

[2] ____________________________________________________

[3] ____________________________________________________

LOCATION: _____________________________________________________________

(FOR HCC OFFICE USE ONLY:)

DATE RECEIVED: _______________________________________________

DATE EMPLOYEE SEEN: __________________________________________

MSDS'S FURNISHED: ____________________________________________

EXPLAINED: _______Yes _______No

The above named MSDS's were furnished and explained to me.

SIGNATURE OF EMPLOYEE: __________________________________ DATE:_________

HCC SIGNATURE: _________________________________________________________

NEW YORK STATE PSYCHIATRIC INSTITUTE

HAZARDOUS CHEMICAL INCIDENT REPORT

DATE: _____________________________

BUILDING: _________________________ FLOOR: ________________ ROOM: ________________

DESCRIPTION OF INCIDENT:

____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________PERSONNEL INVOLVED:

_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________CHEMICALS INVOLVED ... (QUANTITY):

_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

EXTENT OF EXPOSURE:

_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

CLEAN-UP PROCEDURE:

_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

NOTES:______________________________________________________________________________________________________________________________________________________________________________

HCC SIGNATURE: ____________________________________________ DATE: __________________

cc: Safety office

Safety Committee

HCS Committee

Personnel

ACCIDENT REPORT FORM

Index