Biosafety Program - Laurentian University Office Files...3.3.6 Biosafety Program 3.3.7 Laboratory...

BIOSAFETY PROGRAM

Approval Date: 09/08/2016

Category: OHS

Document No.: LSP-02

Revision: 4 Subject: Biosafety Program Administrative Authority: Office of Occupational Health and Safety

Approval Authority: Vice President, Research

Next Review: July 2019

Contact Vice President Research Rui Wang Phone: 705-675-1151 Email: [email protected]

Biosafety Officer Gail Cowper Benoit Phone: 705-675-1151 ext 3061 Fax: 705-675-6522 Email: [email protected]

Biosafety Program Questions regarding this program should be addressed to the Biosafety Officer.

Table of Contents POLICY ON LAB SAFETY ..................................................................................................... 3

(INCLUDING BIOSAFETY AND RADIATION SAFETY) .................................................................... 3

1 Purpose ............................................................................................................................................. 3

2 Scope ................................................................................................................................................ 3

3 Principles .......................................................................................................................................... 4

4 Policy Statement ............................................................................................................................... 5

1 LAURENTIAN UNIVERSITY BIOSAFETY PROGRAM .............................................................. 6

1.1 Purpose .................................................................................................................................... 6

1.2 Scope ........................................................................................................................................ 6

1.3 Related documents .................................................................................................................. 6

1.4 Definitions ................................................................................................................................ 6

1.5 Responsibilities........................................................................................................................ 7

1.5.1 Overall Responsibilities ................................................................................................... 7

1.5.2 Organizational structures ................................................................................................ 7

1.53 Health and Safety Committee. ........................................................................................ 8

1.5.4 Lab Safety Committee ..................................................................................................... 8

1.5.5 Other Centers ................................................................................................................ 10

1.5.6 Revisions of the RSP ...................................................................................................... 10

1.6 Authority and Responsibilities ............................................................................................... 11

1. 6.1 Vice-President, Research ............................................................................................... 11

1.6.2 Biosafety Officer ............................................................................................................ 11

1.6.3 The Alternate Biosafety Officer (ABSO) ......................................................................... 11

1.6.4 The Principle Investigator (PI) ....................................................................................... 11

1.6.5 The Biosafety Worker .................................................................................................... 12

1.6.6 The Purchasing Personnel ............................................................................................. 12

1.6.7 The Receiving Personnel ................................................................................................ 12

1.6.8 Standard Operating Procedures (SOP) .......................................................................... 12

2 APPLICATION TO USE BIOHAZARDOUS MATERIALS ......................................................... 12

2.1 Application of the Terms of Reference of the Use of Biohazardous Materials in Research

and Teaching .......................................................................................................................... 13

2.2 Steps taken by the PI .............................................................................................................. 13

2.3 Steps taken by the Biosafety Officer ...................................................................................... 13

2.4 Annual Reports and Renewals ............................................................................................... 14

3 RISK ASSESSMENTS ........................................................................................................... 14

3.1 Rules Involving Potentially Hazardous Biological Agents ....................................................... 15

3.2 The University’s BSO will consider following questions in performing the risk assessment: 16

3.3 Classification of Biological Agents Risk Groups ...................................................................... 16

3.4 Levels of Biological Containment ........................................................................................... 17

3.5 To assess the dual-use potential, the BSO must first ask these questions: ........................... 17

4 BIOSAFETY PROGRAM INSPECTION PROTOCOL ............................................................... 19

4.1 Regulations ............................................................................................................................. 19

4.2 Principal Investigator Inspection Responsibilities .................................................................. 19

4.3 Lab Safety Committee Responsibilities .................................................................................. 19

4.4 Biosafety Officer Responsibilities ........................................................................................... 19

4.5 First Formal Inspection .......................................................................................................... 19

4.6 Second Formal Inspection ...................................................................................................... 20

4.7 Review of Written Response .................................................................................................. 20

4.8 3rd Formal Inspection ............................................................................................................. 20

4.9 Consultation Outcome ........................................................................................................... 20

4.10 Immediate Dangers ................................................................................................................ 20

4.11 Appeals ................................................................................................................................... 21

5 INVENTORY CONTROL ....................................................................................................... 21

6 MEDICAL SURVEILLANCE PROGRAM ................................................................................ 21

8 TRAINING/INFORMATION DELIVERY ................................................................................ 21

9 SAFE LAB PROCEDURES AND DIRECTIVES ......................................................................... 23

10 REVISIONS ......................................................................................................................... 23

APPENDIX A: JOINT HEALTH AND SAFETY COMMITTEE TERMS OF REFERENCE ..................... 24

APPENDIX B: JOINT HEALTH AND SAFETY COMMITTEE MEMBERS ......................................... 28

APPENDIX C: LAB SAFETY COMMITTEE TERMS OF REFERENCE ............................................... 30

APPENDIX D: BIOSAFETY RISK ASSESSMENT FORM ................................................................. 32

APPENDIX E: BIOSECURITY PLAN .............................................................................................. 36

APPENDIX F: BIOSAFETY PERMIT APPLICATION ...................................................................... 39

Policy on Lab Safety

(Including Biosafety and Radiation Safety)

Office of Administration: Vice-President, Research

Approval Authority: Vice-President, Research

Approval Date: September 8, 2016

Next Review : July 2017

Review History July 2012; July 2014; July 2015; September 2016

1 Purpose This policy is intended to:

1.1. Ensure compliance concerning safety in a laboratory setting to the obligations of the Ontario

Occupational Health and Safety Act and Regulations;

1.2. Prevent accidents and injuries in a laboratory setting and to provide and maintain a safe and

healthy work environment for all employees, students and visitors;

1.3. Identify roles and responsibilities for handling health and safety concerns in a laboratory

setting including appropriate consultation and input, approval and administration of

laboratory safety procedures as explained in the Laboratory Safety Programs;

1.4. Protect employees, students and the community and the environment from the risks which

may arise in the handling of potentially hazardous materials, by ensuring that the elements

of the all programs are implemented prior to work being conducted with potentially

hazardous material;

1.5. Integrate recognition, evaluation and control of radiological and biological hazards on

campus and ensure compliance with applicable federal government legislation and

standards.

2 Scope

2.1 This policy applies to all employees, contractors, students, post-doctoral fellows,

volunteers, and visiting scholars for working safely in the laboratory environment.

2.2 All personnel are expected to comply with the University standards for safety, including

radioisotope safety regulations.

2.3 Laurentian University (“the employer”) and all employees working with level 2 biohazards

as defined by the Health Canada in ‘Canadian Biosafety Standard, 2nd edition, 2015 and the

Plan for Administrative Oversight are jointly responsible for the compliance and

enforcement of this policy and all relevant regulations, and to take appropriate steps to

prevent accidents and/or incidents which might have an adverse effects on the health and

safety of workers, the public or upon the natural environment. The employer is ultimately

responsible, through the Vice-President, Research (Vice-President), for the provision of a

safe working environment, as well as for the health and safety of its employees, and is

committed to the provision of funds sufficient for the supply of human and material

resources as may be necessary to carry out these responsibilities.

2.4 Deans, chairs, research supervisors, non-academic managers, and supervisors are

responsible for the safety of employees, students, and visitors who work and study within

their areas of jurisdiction, and for compliance with statutory and university requirements.

2.5 Employees have a duty to protect their own health and safety by working in compliance

with the law, as well as with safe work practices and procedures established by the

university, and to report hazards and violations to supervisory staff for correction.

3 Principles 3.1 The responsibility for the management of laboratory safety and adherence to safe lab

practices rests within units and departments. All personnel, including directors, supervisors,

employees and students have a duty to fulfill their obligations with respect to maintaining a

healthful and safe work environment.

3.2 Discipline or other action may be necessary in instances where work practices or other

activities are in contravention of, or not in accordance with, the University’s Policy on Lab

Safety and its Programs, or other relevant legislation.

3.3 Related policies, procedures, legislation and other documents include:

3.3.1 Occupational Health and Safety Act of Ontario (OSHA), O. Reg. 860 1990

WHMIS

3.3.2 Transportation of Dangerous Goods Act.

3.3.3 Canadian Biosafety Standard, 2nd Edition, 2015.

3.3.4 General Nuclear Safety and Control Regulations (SOR/2000-202).

3.3.5 Radiation Safety Program

3.3.6 Biosafety Program

3.3.7 Laboratory Safety Program

3.3.8 Laboratory Safety Guidelines

4 Policy Statement

4.1 Laurentian University recognizes the value of every member of the campus community,

and it is, therefore, vitally interested in the health and safety of all persons working,

studying, residing, or visiting on or within its premises, wherever situated.

4.2 This policy is intended to provide directives and describe the University’s position on

laboratory safety issues. It acts to ensure that laboratory safety practices and processes

are in complete conformity with all relevant statutes and regulations pertaining to post-

secondary institutions in the Province of Ontario.

4.3 Information presented in all Laboratory Safety Programs provides directives on dealing

with various laboratory safety concerns. Every worker/student working in a lab must be

instructed on safe work procedures as well as participate actively in the implementation of

these safe work practices.

4.4 In the event of an incident in a laboratory that may pose a health and safety concern, the

incident must be reported to the supervisor by the individual. Supervisors are referred to

the resources listed in the Laboratory Safety Program.

1 Laurentian University Biosafety Program

1.1 Purpose

1.1.1 To protect employees, students and the community and the environment from the risks which may arise in the handling of potentially hazardous biological materials, by ensuring that the elements of the biosafety program are implemented prior to work being conducted with potentially hazardous biological material:

a. Supervisor planning to work with biohazardous material file a biohazard application with the Biosafety Officer.

b. Approval is obtained from the Biosafety Officer prior to work commencing. c. Containment facility has been approved by the Biosafety Officer. d. The level of training of the persons assigned to the project has been approved by the

Lab Safety Committee.

1.1.2 To ensure compliance with the Occupational Health and Safety Act (OHSA) and Regulations, Environmental Protection Act and the guidelines of Health Canada, the National Science and Engineering Research Council (NSERC), and all applicable federal and provincial regulations respecting biohazardous material management.

1.2 Scope

1.2.1 All teaching and research projects which use:

a. Infectious biological agents b. Potentially oncogenic biological materials c. Recombinant DNA which may be hazardous to humans, animals, or other life forms d. Human and simian cell cultures and bodily fluids e. Transgenic material which may be hazardous to humans, animals and plants and the

environment f. Parasites

1.2.2 All persons who work with or arrange for transportation of biohazardous material.

1.3 Related documents

1.3.1 Occupational Health and Safety Act of Ontario (OSHA), O. Reg. 860 1990 WHMIS 1.3.2 Transportation of Dangerous Goods Act. 1.3.3 Canadian Biosafety Standard, 2nd edition, 2015 1.3.5 Laurentian University Laboratory Safety Program 1.3.6 Laurentian University Laboratory Safety Policy 1.3.7 Laurentian University Lab Safety Committee Terms of Reference

1.4 Definitions

1.4.1 Biohazardous Material: Bacteria, viruses, parasites, fungi and other infectious agents which are pathogenic to humans. In addition, recombinant DNA or genetic manipulations which may present a risk and all mammalian cell in culture until proven to be free of adventitious agents.

1.4.2 Biological Restricted Area: A physical containment classification based on level of risk or hazard to be encountered while handling biohazardous material. There are four levels of physical containment based on the Health Canada Standards.

1.4.3 Oncogenic Biological Material: A material that induces cancer i.e., malignant tumour. Oncogenic viruses are a typical example of this material.

1.4.4 Physical Containment: Use of physical facilities and equipment and good work practices to prevent the release of organisms into the environment.

1.4.5 Principal Investigator: A faculty or supervisory staff member who is responsible for the research project.

1.4.6 Recombinant DNA: (a) DNA molecules which are constructed outside the living cells by joining natural or synthetic DNA molecules that can replicate in a living cell or (b) DNA molecules that result from the replication of those described in (a).

1.4.7 Risk Group: The Health Canada system of classification of infective pathogens by severity of individual or community risk. Risk group 1 presents the least level of risk and Risk group 4 presents the most risk.

1.5 Responsibilities

1.5.1 Overall Responsibilities

The management of the Biosafety Program (BSP) is by the Biosafety Officer (BSO). The BSO reports to the Manager, Occupational Health and Safety, Laurentian University, and the Vice-President, Research (VP) on matters of biological safety. The Manager, Occupational Health and Safety, and the VP can advise the BSO on the consistency of this BSP on University safety policy. The BSO is the technical representative of the University to the Health Canada Agency for compliance matters. The individual License Holders respond to the BSO for biosafety matters. With regards to potential conflict of interest: The Biosafety Officer and the Office of Health and

Safety reports in through the portfolio of the Director of Professional Relations in order to

eliminate any potential conflict of interest that may arise by reporting to the VPR or Vice-President,

Academic.

1.5.2 Organizational structures

1.53 Health and Safety Committee.

Please see Appendix A for the terms of reference for the Joint Health and Safety Committee. The composition of the Joint Health and Safety Committee as outlined in Laurentian University’s Health and Safety Policies and Procedures is:

Laurentian University Staff Union representative (2) Laurentian University Faculty Association representative (2) Graduate Teaching Assistant (CUPE 5011) representative Lab Safety representative Laurentian University Administrative and Professional Staff Association representative Manager, Health and Wellness Centre Manager of Physical Plant and Parking Director of Security and Risk Management Manager, Occupational Health and Safety Executive Director, Human Resources and Organizational Development

The general role of the Joint Health and Safety Committee include:

Ensuring that inspections of laboratories and facilities are carried out by mandated inspection teams (Joint Health and Safety Committee);

Reviewing of biohazardous materials safety and security programs, including training programs;

Recording and reporting of incidents/accidents to the Lab Safety Committee and regulatory agencies; the management of the implementation of corrective or preventative measures as appropriate;

1.5.4 Lab Safety Committee

Please see Appendix B for the terms of reference for the Lab Safety Committee. The composition of the Lab Safety Committee as outlined in Laurentian University’s Lab Safety Program is: Representative from different departments:

Biology Chemistry and Biochemistry Earth Sciences Engineering Physics Neurosciences NOSM Kinesiology

The different departmental committees (e.g. Chemistry and Biochemistry, Biology, etc.) have different schedules and internal structures. Representatives of these committees can also be present on the Lab safety committee. It is not unusual that members of a committee sit on other committees. Laurentian University’s Lab Safety Committee is authorized to oversee the University’s Lab Safety Program, provide policy direction and make recommendations to the Vice President, Research, for

all matters pertaining to research and teaching in a laboratory setting. This committee will be responsible for reviewing the operational safety of both teaching and research laboratories at the University and for recommending policies and procedures to improve health and safety in these areas. It is intended to provide a mechanism whereby knowledgeable input from laboratory practitioners and others is received, reviewed and utilized to advise the Vice President, Research, on health and safety matters specific to laboratories and the environment.

1.5.5 Animal Care Committee

The LU Animal Care Committee (ACC) is constituted for better service, safer and better research by the Vice-President Research (VPR) who is delegated by the President to have complete authority for the entire animal care and use program. The VPR will ensure that sufficient resources are provided to allow proper functioning of the ACC, including assistance for the documentation of ACC activities. The ACC is specifically empowered by the VPR to review each research, teaching or testing project in which it is proposed that living, non-human vertebrate animals will be used to assure that, in the view of the ACC, the number and species of animals used, the procedures employed, and levels of pain experienced by any animal are appropriate to the proposed project The University ACC is responsible for ensuring that all activities, procedures, and facilities that involve living vertebrate animals are in accord with the letter and the spirit of relevant legislation and guidelines. This shall include distribution of approved standard operating procedures and institutional animal care and use policies Membership is sought out from individuals with experience and expertise in animal welfare and research from University departments and invited collaborating institutes. Membership consists of the following as a minimum of adequate representation of lab and field research:

1. At least 3 faculty or representatives of the University who have experience in animal care and use. It will be beneficial to have each department represented and will require a representative of at least 3 of the following units: Human Kinetics, Biology, Biochemistry, Psychology, Midwifery and NOSM.

2. A minimum of one member of the University faculty or staff not engaged in research, teaching or testing with animals.

3. A minimum of one person, (preferably two) representing community interests and concerns, and who is not affiliated with the university and is not involved in animals used for research, teaching, or testing.

4. The Animal Care Director who is a veterinarian with experience in the field of laboratory animal medicine.

5. One person responsible for the management of the animal research, (Post-Award Officer) – non voting and represents senior administration as well as liaison with the lab safety committee.

6. Minimum of one animal facility animal care technician (preferably two). 7. One graduate or undergraduate student engaged in animal research but not supervised by

one of the members of the ACC. 8. Animal Care Committee Coordinator (non voting) to provide support to the ACC. 9. University Occupational Health and Safety representative who is also the Biosafety and

Radiation Safety Officer.

The term of appointment for members shall normally be four years at the maximum, renewable once, and terms should be staggered to ensure continuity of membership and prevent significant changes in membership over short periods of time. The Chair is appointed by the VPR and will have a normal term of four years.

1.5.6 Other Centers

Other organizations and research centers have formal links with Laurentian University. These organizations have internal radiation safety policies that complement the current Policy document. Those procedures are specific to a need and generally fall under “Laboratory-specific procedures”. These procedures are consistent, and they serve as a complement to this Policy document. All research centers must ensure that their procedures are consistent with the current document.

1.5.7 Revisions of the RSP

The Biosafety program will be reviewed on a yearly basis and recommendations/feedback which may render the program operate more effectively will be taken into consideration as they are brought to the attention of the BSO. Staff and students are encouraged to contact the BSO with any Biosafety questions or concerns, or to report any and all incidents or problems with procedures as they arise. Table 1: Change, action and responsibilities

Type of change and responsibility

Criteria and examples Action

Moderate to major; involves BSO and may require notification to Health Canada

A change that could alter the conditions set in the license: Addition or removal of a building listed where biohazardous work may be performed; A change in personnel responsible of the management and control of biohazardous substances.

Notification to BSO and/or review; Notification and/or advise to Health Canada.

Moderate; require involvement of BSO or License Holder

A change within the limits and restrictions of the license, not leading to a significant increase in biological risk. New operation or procedure that requires a change in risk group classification; Disposal of biohazardous material requiring transport to locations outside the University. Non-compliance issues discovered through inspections or incident reporting.

Keep a copy of the change in the laboratory log book; Consult with License Holder and/or BSO. Review of risk assessment

Minor; License Holder or individual laboratory investigator

A change with little or no safety significance. Disposal of biohazardous material by approved routes for specified quantities; Minor changes in laboratory procedures; Add or delete names of authorized workers; Updates on the training status of workers; Relocation of biohazardous material between authorized laboratories for storage, for quantities below the inventory limit set in the license.

Keep a copy of the change in the laboratory log book; Provide this information during license renewal or when required by BSO. Review of the risk assessment.

Note that this list of items is not exhaustive, and if in doubt, consult with the BSO.

1.6 Authority and Responsibilities

1. 6.1 Vice-President, Research

a. Provides administrative support for the licenses and the;

b. Final administrative authority in the operation of the licensed activities.

c. The person who bill be the linkage to transfer pertinent information to senior

management.

1.6.2 Biosafety Officer

The Biosafety Officer has the authority, on behalf of the Vice-President, Research (Vice-President) to:

a. Review and help license applications and updates; b. Ensure that License Holders operate their laboratories according to the BSP; c. Provide technical support and advise laboratory staff in biosafety matters; d. Provide to the University and to external agencies information and reports on

situations and activities involving biohazards, as required; e. Provide general training to new users; f. Assume control in emergencies involving biohazards and take such actions as may

be necessary to ensure the safety of personnel, property, and equipment, and reports at the earliest possible time to the Vice President, Research;

g. Request any recommendations for biosafety enhancements to the Vice President, Research.

h. Stop immediately any use of biohazardous material which deviates from the approval outlined in the Biosafety certificate or is deemed to be in non-compliance with the applicable standards.

i. Inspect and audit laboratories and other workplaces where biohazards are present; j. Advise the Vice-President, Research and license holders on new Federal and

Provincial legislation or items which may affect the use of biohazards on campus; k. When asked by Purchasing, review the purchase orders of biohazardous materials

and checks these against issued permit; l. Keeps a duplicate inventory file of biohazardous material (Note: it is the task of the

individual principle investigators to keep the inventory up-to-date and give a copy to the BSO);

1.6.3 The Alternate Biosafety Officer (ABSO)

1. Replaces the BSO in his/her absence, or as directed by the VP;

1.6.4 The Principle Investigator (PI)

1. Ensure the safe conduct of operations in the Laboratory, including the wearing of appropriate safety equipment;

2. Keep an up-to-date list of workers and their training; 3. Provide support to the BSO in license applications; 4. Provide laboratory-specific training, and review specific procedures for compliance with

this BSP and other safety measures; 5. Report all incidents involving biohazard material to the BSO; 6. Keep an inventory of all biohazardous material, acquisitions and dispositions; 7. Supervise and/or dispose of the wastes generated in his/her laboratory according to the

policies set in this BSP, and takes care of the costs as a part of the research activities. 8. Ensure that the Laboratory or Facility is secured against unauthorized access.

9. Arrange for adequate facilities, equipment, etc., in compliance with this BSP. It is the responsibility of an Investigator to have adequate facilities, and to solicit the usual funding sources of research for improving the Facilities or equipment;

10. Ensure that all workers have proper biosafety training, including visitors. The Individual Investigator has the authority to disallow a worker from working with radiation if the worker does not perform satisfactorily, of if the worker does not provide sufficient proof of training.

11. Posting of warning signs and labels as require.

1.6.5 The Biosafety Worker

1. Comply with this BSP; 2. Comply with other laboratory-specific safety regulations not listed in this document; 3. Report any biosafety incident to the Principle Investigator or BSO (as applicable) as soon as

reasonably possible after the event, consistent with University Policy; 4. Properly label and store biohazardous material, and to properly record and label the

wastes; 5. Keep the biohazard inventory logbook up-to-date.

1.6.6 The Purchasing Personnel

1. Keep a duplicate copy of the permits; 2. Review the purchase orders of biohazardous materials and confirm with the BSO that the

material fall within the scope of the issued permit;

1.6.7 The Receiving Personnel

1. Inspect parcels of biohazardous shipments, upon receiving, for damage; 2. If damage is present and there is evidence of leak, do not accept shipment and consult the

BSO prior to returning or moving the item, to avoid the spread of contamination; 3. Safely handle and deliver the purchased radioisotopes to the authorized laboratories.

1.6.8 Standard Operating Procedures (SOP)

SOPs and other guidelines for project approval, inspections, acquisition, use, storage, and disposal of biohazardous materials are developed and published by the Biosafety Officer after having been approved by the Lab Safety Committee.

2 Application to Use Biohazardous Materials

In order to use biological agents a Principal Investigator must hold a valid Biological Safety permit

and Biological Workers must be listed on a permit. The Biological Safety permit system registers

users and collects / documents information for the investigators inventory and overarching risk

assessment. Permits are accepted, reviewed and approved by the Biological Safety Officer. In this

part of the process the Biological Safety officer has the opportunity to review the general scope of

work for the applicant as well as the biological agent inventory (held or proposed inventory) for

risks including agents with possible dual use potential. Permits are valid for 2 years and must be

updated within 30 days when key factors or personnel changes occur. The permit application

process is described in greater detail below.

2.1 Application of the Terms of Reference of the Use of Biohazardous

Materials in Research and Teaching

a) Research and teaching involving biohazardous material shall be carried out in accordance with the applicable laws such as the Occupational Health and Safety Act, the Canadian Biosafety Standards from the Public Health Agency of Canada.

b) All research, teaching or training activities using biohazardous material shall be approved by the Biosafety Officer before use can commence. Any modification of the original and approved protocol shall be submitted for approval prior to making these modifications to an experiment.

2.2 Steps taken by the PI

1. Review and understand Laurentian University’s Lab Safety Policy. 2. Ensure that:

a. The physical laboratory environment meets the standards required for the Biohazard level applied.

b. A laboratory procedures manual is available in the lab. The manual shall meet the standards outlined in the “Laboratory Safety Handbook”.

c. All personnel and students working in the laboratory shall have been trained prior to having access to the lab. Evidence of this training shall be recorded in writing with the Biosafety Officer.

3. It is recommended that the application be reviewed by the Biosafety Safety Officer prior to submission. The application form is available from the Biosafety Safety Officer or from the Occupational Health and Safety (Biosafety) website and from the Research website. The PI submit application to the Biosafety Officer at least two weeks before the planned commencement of the project, consisting of hard and electronic copies of the following: a. Application form (https://intranet.laurentian.ca/upload/0/biosafety-

august2010_distributed.pdf ) b. Develop a laboratory specific procedure manual for your project/course. c. Training records. d. Local Risk Assessment Form

(https://intranet.laurentian.ca/upload/0/1262/9775/9778/Local%20Risk%20Assessment.pdf)

e. Biosecurity Plan (https://intranet.laurentian.ca/?q=node/8886 ) 4. The Biosafety Officer will review the application. If all written documents are in order,

the Biosafety Officer shall undertake a facility inspection within 10 working days. Once all criteria are met, a Biosafety Permit will be issued. Biosafety permits shall be granted for no more than two years and shall require bi-annual review. Site inspections by the Biosafety Officer are required every six (6) months.

2.3 Steps taken by the Biosafety Officer

1. The Biosafety Officer shall inform the PI of the decision in writing. 2. Upon a project’s approval, the Biosafety Permit information shall be submitted to the

Office of Research Services. The Occupational Health and Safety Office shall retain signed copies of all approved applications and permits.

https://intranet.laurentian.ca/upload/0/biosafety-august2010_distributed.pdf

https://intranet.laurentian.ca/upload/0/biosafety-august2010_distributed.pdf

https://intranet.laurentian.ca/upload/0/1262/9775/9778/Local%20Risk%20Assessment.pdf

https://intranet.laurentian.ca/upload/0/1262/9775/9778/Local%20Risk%20Assessment.pdf

https://intranet.laurentian.ca/?q=node/8886

3. If the project is not approved, the PI shall be asked for more information, and may be required to submit a revised project proposal for review by the Lab Safety Committee. If these actions fail to lead to approval of the project, the Biosafety Officer shall provide the PI with a written statement of reasons for non-approval of the project within 10 working days.

4. Within 15 working days of receiving a decision that the project has not been approved the PI has the right to appeal, by asking for a hearing before the Lab Safety Committee. In the event the appeal is not successful, the PI may appeal to the Vice-President, who may appoint an appeal committee. The decision of that committee, if ratified by the Vice-President, shall be final.

2.4 Annual Reports and Renewals

1. The PI shall renew their research and/or teaching applications every year. Any minor changes to the application shall be submitted as an amendment and approved by the Biosafety Officer at least two weeks before implementation. Major changes shall require the submission of a new application.

2. The PI shall notify the Biosafety Officer of any changes in agent(s), procedure(s) or personnel, using the Biosafety Renewal/Amendment Form. Should there be any changes in procedures or work activity, the PI will submit a new local risk assessment form to the BSO for approval.

3. The PI shall update training for new personnel and ensure that the training records are up to date.

4. The PI shall provide an updated inventory of all biohazardous material in use or in storage.

3 Risk Assessments

The Lab Safety Committee reviews both the overreaching and the local risk assessments

and make recommendations to ensure compliance. These are evaluated on an annual

basis or sooner should circumstances change.

Risk assessment is a critical step in the selection of an appropriate containment level for

the biohazardous work to be carried out. Upon review of the biosafety certificate, the BSO

will conduct a detailed local risk assessment to determine whether work requires

containment level 1 or 2 facilities and operational practices. Biological Safety and

biosecurity risks are controlled by the Principal Investigators according to

recommendations made by the Biological Safety Officer during the permit application

process and the Biological Safety Advisory Committee during the certificate application

processes.

Available information can be used as a starting point to assist in the identification of risk

factors, including the recommended Risk Group of the organism. In addition to the Risk

Group classifications, which are based on the risk factors inherent to the organism, the

following factors associated with the laboratory operation should also be examined:

• potential for aerosol generation

• quantity and concentration of the agent

• agent stability in the environment (inherent biological decay rate)

• type of work proposed (e.g., in vitro, in vivo, aerosol challenge studies)

• use of recombinant organisms (e.g., gene coding for virulence factors or

toxins; host range alteration;

• oncogenicity; replication capacity; capability to revert to wild type).

Due to the relatively small number of activities with biohazardous material that is carried

out at Laurentian University, it is not a complex process to identify and assess risks. As part

of the ongoing risk control strategies, where teaching activities using RG2 pathogens could

be modified, RG1 microorganisms have been introduced and replaced RG2 material.

However some RG2 material in use cannot be replaced due to the nature of the

experiment requiring those specific microorganisms.

3.1 Rules Involving Potentially Hazardous Biological Agents

The use of potentially hazardous microorganisms (including bacteria, viruses, viroids, prions, fungi and parasites), recombinant DNA (rDNA) or human or animal fresh/frozen tissues, blood, or body fluids is allowable under the conditions and rules that follow. Experimentation involving culturing of potentially hazardous biological agents, even RG-1 organisms, is prohibited in a home environment.

a) Research determined to be risk group levels 3 or 4 is prohibited at Laurentian University.

b) Studies intended to genetically engineer bacteria with multiple antibiotic resistance are prohibited. Extreme caution should be exercised when selecting out antibiotic resistant organisms. Studies involving such organisms require at least RG-2 containment.

c) A risk assessment must be conducted by the research staff prior to experimentation and a final biosafety level must be determined or confirmed by the BSO.

d) Research to be determined to be Risk Group Level 2 (RG-2) must be conducted in a laboratory rated CL-2.

e) All potentially hazardous biological agents must be properly disposed of at the end of experimentation in accordance with their biosafety level.

f) Studies involving the culturing of human or animal waste, including sewage sludge, must be treated as RG-2 study.

g) All rDNA technology studies involving RG-1 organisms and RG-1 host vector systems may be conducted in a RG-1 laboratory.

h) All rDNA technology study that involves RG-1 agents that may convert to RG-2 agents during the course of experimentation must be conducted entirely in a CL-2 facility.

i) All rDNA technology studies involving RG-2 organisms and/or RG-2 host vector systems must be conducted in a CL-2 facility.

j) Propagation of recombinants containing DNA coding for oncogenes or other human, plant or animal toxins (including viruses) is prohibited.

k) Biosafety level 2 studies involving the collection and examination of fresh/frozen tissues or body fluids include those that may contain microorganisms belonging to RG-1 or 2.

l) All studies involving human or wild animal blood or blood products should be considered a RG- 2 studies and must be conducted in a CL-2 facility. However, if these studies involve collection from non-infectious source with little likelihood of microorganisms present, they can be considered a RG-1 study.

m) The following types of tissue do not need to be treated as potentially hazardous biological agents:

i. Plant tissue ii. Established cell and tissue cultures. The source and catalog number of

the cultures should be identified. iii. Meat or meat by-products obtained from food stores iv. Hair v. Teeth that have been sterilized to kill any blood borne pathogen that

may be present. vi. Fossilized tissue or archeological specimens

vii. Prepared fixed tissue

3.2 The University’s BSO will consider following questions in performing the

risk assessment:

a) What is the strategy or strategies being implemented by the institution/organization to address the risks (e.g., applying specific biosafety and biosecurity measures or modifying experimental design or methodology such that an attenuated strain is used or strain’s ability to proliferate outside of the lab or within different hosts is limited by using a different technique)?

b) Are there currently any counter measures (e.g., treatments) to help mitigate the potential consequences? Are they readily available?

c) How will the results or products of the research be shared or distributed (i.e., will the results or products be shared openly or remain within the laboratory or institutions)?

d) How readily available are these results? Who will have access to the knowledge, information, technology, or final products?

e) Risk assessment defines the potential level of harm, injury or disease to plants, animals and humans that may occur when working with biological agents. The end result of a risk assessment is the assignment of a final biosafety level which then determines the laboratory facilities, equipment, training, and supervision required for the research project to proceed.

f) Incidents (such as spills) and non-compliance issues will generate a review of risks and post-approval review.

3.3 Classification of Biological Agents Risk Groups

Biological agents, plant or animal, are classified according to biosafety level risk groups. These classifications presume ordinary circumstances in the research laboratory, or growth of agents in small volumes for diagnostic and experimental purposes. RG-1 risk group contains biological agents that pose low risk to personnel and the environment. These agents are highly unlikely to cause disease in healthy laboratory workers, animals or plants. The agents require Biosafety Level 1 containment. Examples of RG-1 organisms are: Escherichia coli strain K12, Agrobacterium tumifaciens, Micrococcus leuteus, Neurospora crassa, Bacillus subtilis. RG-2 risk group contains biological agents that pose moderate risk to personnel and the environment. If exposure occurs in a laboratory situation, the risk of spread is limited and it rarely would cause infection that would lead to serious disease. Effective treatment and

preventive measures are available in the event that an infection occurs. The agents require Biosafety Level 2 containment. Examples of RG-2 organisms are: Streptococcus pneumonia, Salmonella choleraesuis. RG-3 risk group contains biological agents that usually cause serious disease (human, animal or plant) or that can result in serious economic consequences. PROHIBITED RG-4 risk group contains biological agents that usually produce very serious disease (human, animal or plant) that is often untreatable. PROHIBITED

3.4 Levels of Biological Containment

There are four levels of biological containment (Biosafety Level 1 - 4). Each level has guidelines for laboratory facilities, safety equipment and laboratory practices and techniques. CL-1 containment is normally found in water-testing laboratories, in high schools, and in colleges teaching introductory microbiology classes. Work is done on an open bench or in a fume hood. Standard microbiological practices are used when working in the laboratory. Decontamination can be achieved by treating with chemical disinfectants or by steam autoclaving. Lab coats are required and gloves recommended. The laboratory work is supervised by an individual with general training in microbiology or a related science. CL-2 containment is designed to maximize safety when working with agents of moderate risk to humans and the environment. Access to the laboratory is restricted. Biological safety cabinets (Class 2, type A, BSC) must be available. An autoclave should be readily available for decontaminating waste materials. Lab coats, gloves and face protection are required. The laboratory work must be supervised by a competent scientist who understands the risk associated with working with the agents involved.

3.5 To assess the dual-use potential, the BSO must first ask these questions:

A project based risk assessment is conducted using the local risk assessment form which is

submitted to the BSO for review. The certificate process collects / documents more

detailed information regarding the specific agents and procedures in a proposed project. A

Principal Investigator submits a Certificate application when they receive grant funding.

Funds are released by the Office of Research Services only after the applicant provides an

approval certificate to the Office of Research Services. In order to receive certificate

approval the committee must be satisfied that the containment level and safety

procedures identified are appropriate for the proposed work. The certificate is valid until

the grant expires. The detailed review conducted by experts appointed to the committee

for certificate approval is the most appropriate to identify dual use agents, knowledge,

technology or intermediate and final products.

In order to identify research which may have dual-use potential, the BSO, along with the

responsible researcher, shall consult the decision tree provided in the Plan for the

Administrative Oversight for Pathogens and Toxins in a Research Setting- Required

Elements and Guidelines by The Public Health Agency of Canada :

Once the dual-use potential has been confirmed, a risk assessment must be performed to

assess the ways in which pathogens, knowledge, technology or products (e.g., toxin) could

be misused, the ease with which they may be misused, and the scope and magnitude of

the potential consequences of misuse.

Considerations of the following questions can help when performing the risk assessment:

What types of pathogens, knowledge, technology, or products are anticipated to be

generated through the research?

How could pathogens, knowledge, technology, or products resulting from the research

be misused to pose harm to public health and safety or national security?

What type of technical skills will be required to repeat the experiment?

Are the materials, tools and equipment expensive or difficult to acquire?

If released outside the laboratory, will the pathogen affect humans and/or animals?

What is the likelihood that the knowledge, information, technology, or products from

the research will be used to harm public health and safety, the environment (including

animals) or national security?

What is the scope and magnitude of the potential risk(s) identified?

4 Biosafety Program Inspection Protocol

4.1 Regulations

Regulations pertaining to biohazard safety include 1) those from Canadian Federal Agencies, 2) those from agencies that provide funding, 3) the Workers Safety Insurance Board, 4) transport regulations, 5) University policies, and 6) codes of best practice.

4.2 Principal Investigator Inspection Responsibilities

a. Completes an inspection of containment zones monthly. b. Reports significant problems, illnesses suspected of originating from biohazard work,

incidents, or instances of non-compliance/non-conformance. c. PI may delegate inspection responsibilities to other lab personnel. d. The Biosafety Safety Officer is available for consultation and guidance.

4.3 Lab Safety Committee Responsibilities

a. The Lab Safety Committee (hereafter referred to as the committee) shall investigate and report on incidents relating to biosafety brought to its attention whenever it is believed or suspected that any breach of compliance or conformance or other safety hazard may have occurred or is occurring.

b. Committee members who are trained in biosafety to the satisfaction of the committee may enter any containment level laboratory or its related premises under the jurisdiction of LU, at any time, to examine items related to biosafety operational procedures or physical containment.

c. The committee shall deny a biosafety permit where previous indications of non-compliance/non-conformance indicates an unacceptable risk.

4.4 Biosafety Officer Responsibilities

a. Promote and monitor compliance with policies, regulations and procedures for safe use, handling, monitoring, storage, transport, and disposal of biohazardous materials.

b. The committee is responsible for conduction and/or delegating inspections. c. Inspections shall be regularly conducted and of such frequency so as to provide an

assurance to the University that all labs are reasonably believed to be in compliance and conformance with this policy. At the minimum inspections shall be undertaken by the committee at least once every year.

d. Advise the Vice-President, and the committee on matters related to non-compliance/non-conformance.

e. Advise the Vice-President of the potential for dual use research, who will then determine How the results or products of the research be shared or distributed based on risk assessment. Who will have access to the knowledge, information, technology, or final products.

f. Be available for consultation on problems. g. Ensure proper maintenance of records. h. Investigate reports of biosafety non-compliance/non-conformance with the

committee.

4.5 First Formal Inspection

a. Inspections shall identify items requiring attention and a written list of these items will be made available to the PI.

b. Items that were rectified during the inspection shall be noted by the Biosafety Officer.

c. Items that cannot be rectified immediately shall necessitate a 2nd inspection within 15 working days.

4.6 Second Formal Inspection

Will be conducted to determine whether the items requiring rectifying were addressed in a timely fashion. A summary of the inspection results will be made available to the PI and to the committee. The committee, upon reviewing the 2nd inspection results, may:

a. File a report in Occupational Health and Safety Office (OHS) and notify the PI that the laboratory or area is in compliance/conformance; or

b. Issue a notice to the PI requesting a written response to indicate either 1) how compliance/conformance will be attained and/or 2) why the PI believes the laboratory and personnel are in full compliance/conformance.

4.7 Review of Written Response

If the committee has requested a written response, which shall be provided by the PI within 15 working days, the committee will review that response within 15 working days and:

a. If the committee concurs that the laboratory or area is in compliance/conformance, the committee shall so notify the PI and OHS

b. If the committee believes that the written proposed actions will not suitably address the non-compliance/non/conformance, the committee shall so notify the PI, and schedule a 3rd inspection for verification; or

c. If the committee believes that the laboratory or its personnel will remain in a state of non-compliance/non-conformance, the committee will engage in communication with the PI until such time as the committee deems that a 3rd inspection or alternate action (such as permit suspension) is appropriate. If the permit is suspended, the committee shall notify the Vice-President and the granting agencies.

4.8 3rd Formal Inspection

A 3rd Formal Inspection shall be conducted under the condition noted above. A summary of results will be made available to the PI and to the committee. The committee upon reviewing the 3rd inspection results may: a. File a report in OHS and notify the PI that the laboratory or area is in compliance/non-

conformance, or b. If the committee believes that the laboratory or its personnel will remain in a state of

non-compliance/non-conformance, the committee shall engage in communication with the PI until such time as the committee deems that alternate action is appropriate or suspend the permit.

4.9 Consultation Outcome

a. File a report in OHS and notify the PI that the laboratory or area is in compliance/conformance, or

b. Notify the Vice-President, the PI and granting agencies that the permit is suspended.

4.10 Immediate Dangers

If an immediate danger to people or the environment is observed, the committee may immediately suspend the biosafety permit for that work and require the cessation of that work. The committee shall notify the Vice-President and OHS of the suspension.

4.11 Appeals

Decisions of the committee may be appealed to the Vice-President.

5 Inventory Control

PI will ensure that only authorized personnel have access to infectious material and

toxins.

PI will keep a current inventory of all infectious materials and toxins which will include

a description of the material, including risk group, quantity (where possible), and form,

the location.

The BSO may request an annual update of inventories of infectious materials and

toxins.

Authorized individuals who use information that identifies members must observe

appropriate safeguards, such as keeping user identification and passwords secret,

using only their own passwords for access, signing off applications when appropriate,

protecting inventory records from unauthorized access, and accessing and disclosing

information based on legitimate business need to know.

6 Medical Surveillance Program The purpose of the medical surveillance program is to help prevent and detect illnesses

related to the exposure of personnel to infectious material or toxins.

Risk assessments of the containment zone and work conducted will determine if there

is a risk of lab acquired infections.

If a risk of lab acquired infections is present the PI will inform the individuals working

with the material of any preventative measures available against the infectious

material or toxins, such as vaccinations and/or other treatments, along with the risks

and benefits of these vaccinations and treatments. The PI may also request a pre-

placement medical surveillance for new personnel prior to commencing activities.

When changes are made to a research program (e.g. change in the infectious material

or toxins used) the medical surveillance program must be updated accordingly.

8 Training/Information Delivery Wherever applicable, awareness of the biosafety program is included in new

employee and student orientation including the plan for administrative oversight. The responsibility for providing this orientation and for ensuring that generic guidelines are understood and specific procedures are followed belongs to the supervising faculty member. Faculty Deans, Chairs and Directors have the responsibility for ensuring that faculty members carry out the requirements of this section.

Additional information for the Biosafety Program (General Laboratory Procedures Containment Level 1 and 2, and application guidelines and forms) are available by contacting the Biosafety Officer in the Human Resources Office.

All researchers and students must complete a refresher training every two years to review the biosafety program and all of its elements.

All updates are discussed during lab safety meetings and are announced through emails and then posted on LUNET: https://intranet.laurentian.ca/?q=node/6966&head=1

https://intranet.laurentian.ca/?q=node/6966&head=1

9 Safe Lab Procedures and Directives

Biological Safety and biosecurity risks are controlled by the Principal Investigators according

to recommendations made by the Biological Safety Officer during the permit application

process. These recommendations and specific procedures can be found in Laurentian’s

Laboratory Safety Program which includes all specific safe lab procedures involving

Biohazards (e.g. PPE, BSC use, Emergency response).

10 Revisions The document was revised in July 2017. Next revision date is July 2019.

The Biosafety Program should be effective for the normal duration of a license (5 years). If interim revisions are needed, the change criteria are listed in Table 1.5.7 , along with the responsibilities of the individuals.

APPENDIX A: Joint Health and Safety Committee Terms of Reference

Joint Health and Safety Committee Terms of Reference

(Sudbury Campus)

1. Purpose The purpose of the Joint Health and Safety Committee (JHSC) shall be to protect and enhance

the health and safety of all employees. This will be accomplished primarily through the

functions ascribed to it under the Occupational Health and Safety Act of Ontario (Act):

identify potential hazards;

evaluate these potential hazards;

recommend corrective action to management;

follow-up implemented recommendations.

2. Membership Membership of the JHSC will consist of 12 members representing workers and management on

the main campus at 935 Ramsey Lake Road in Sudbury, including “Living With Lakes”, made up

as follows:

Laurentian University Faculty Association (LUFA) 1 (Worker)

Laurentian University Faculty Association (LUFA) 1 (Worker)

Laurentian University Staff Union (LUSU) 1 (Worker)

Laurentian University Staff Union (LUSU) 1 (Worker)

Lab Safety Committee 1 (Worker)

Graduate Teaching Assistants (CUPE Local 5011) 1 (Worker)

Laurentian University Administrative and Professional Staff Association

(LUAPSA) 1 (Management)

Human Resources and Organizational Development (Executive Director) 1 (Management)

Health and Wellness Services (Manager) 1 (Management)

Physical Plant and Parking (Director or Designate) 1 (Management)

Security and Risk (Director or Designate) 1 (Management)

Occupational Health and Safety (Manager) 1 (Management)

In the event that a JHSC member is unable to attend a committee meeting, an alternate member may attend in her/his place.

3. Selection of Members The members representing workers will be selected by their group or bargaining unit,

according to the procedures of that bargaining unit or group.

The staff members representing management will be appointed by the Executive Director,

Human Resources and Organizational Development; the management member representing

LUAPSA will be selected by her/his group.

4. Functions and Powers The functions, powers and responsibilities of the JHSC will be:

a) those set forth in the Occupational Health and Safety Act of Ontario, on a non-exclusive

basis;

b) those agreed to on a contractual basis between the Union and the Employer;

c) those agreed to by both Management and the JHSC.

Members will encourage fellow employees to work safely and to report hazardous or unsafe

conditions immediately to their supervisor.

Members are bound by confidentiality during and after the period of membership, except

where disclosure of information is specifically required by legislation.

5. Term of Office Due to the complexity of the various pieces of legislation involved and the varied

responsibilities of the members covered therein, coupled with the goal of achieving a level of

competence which will ensure both compliance of the Regulations and service to their various

constituents, members will serve a minimum of two years on this committee, and may, at the

discretion of the member and/or their respective groups, serve longer.

6. Election of Co-chairs and Officers Members representing workers will elect one Co-chair annually at the first general meeting of

the academic year. The Co-chair representing management will be appointed by the Executive

Director, Human Resources and Organizational Development. Co-chairs may serve consecutive

terms.

The Manager, Occupational Health and Safety, or designate, will serve as Secretary of the

meetings, will provide secretariat and liaison services, as necessary, for the JHSC, and provide

or arrange for other services as may be required.

7. Meetings Meetings will be scheduled by the JHSC (at least) every three months in accordance with the

Occupational Health and Safety Act. Special meetings may be called at the request of the Co-

chairs. Members or alternates will attend Committee meetings regularly.

The agenda will be prepared by the Secretary in consultation with the Co-chairs and will be

distributed to the members at least one week prior to each meeting. Additional items may be

added at the meeting.

A quorum will consist of four members, and will include at least two worker and two

management representatives. Regular members will ask alternate members to attend the

JHSC meetings when he/she cannot attend. Meetings may be held without quorum if there is

no objection from any member present. Such meetings will be to provide information and

updates only. Items that must be voted upon will be held over until the next meeting when

quorum is present.

Agreement on issues and recommendations will generally be achieved by consensus. Co-chairs

will meet with senior management to discuss any matters that cannot be agreed to by the

Committee.

The two Co-chairs will chair alternate meetings.

Minutes will be signed by the presiding Co-chair and Secretary and distributed to the

Committee members, the President, the Vice-President (Administration), the Director of

Physical Plant and Planning and the Unions/Associations following each meeting. The minutes

will be approved by the members at the next following meeting.

Minutes, reports and other supporting documentation will be kept by the Secretary and are

available to any JHSC member.

8. Workplace Inspections Inspection teams consisting of at least one worker member and one management member of

the JHSC shall inspect the physical condition of the entire workplace annually in accordance

with a written schedule established by the Committee.

All occupational health-and-safety concerns found during the inspections shall be recorded on

the Laurentian University Workplace Inspection Form. The members conducting the

inspections shall forward a copy of the completed Workplace Inspection Form to the

appropriate area supervisor(s) and to the Manager, Occupational Health and Safety.

9. Resources and Facilities The University will provide a room for the meetings.

A budget for photocopying, copies of legislation and other related administrative services will

be provided by the Department of Human Resources and Organizational

Development/Occupational Health and Safety.

10. Identifications A list of members of the JHSC will be posted in various locations throughout the University and

on LUNET under Human Resources and Organizational Development/Occupational Health and

Safety.

11. Amendments Any amendments to the Terms of Reference will be in accordance with applicable legislation

and will be approved by the Executive Director, Human Resources and Organizational

Development.

APPENDIX B: JOINT HEALTH AND SAFETY COMMITTEE MEMBERS

(2017-2018) WWOORRKKEERR RREEPPRREESSEENNTTAATTIIVVEESS//RREEPPRRÉÉSSEENNTTAANNTTSS DDUU TTRRAAVVAAIILLLLEEUURR

L.U.S.U./S.E.U.L Thomas Matheson Extension/Post 3068 (Co-Chair / Co-présidente) L.U.S.U./S.E.U.L. Physical Plant/Édifice de l’entretien Jordan Pellow Extension/Poste 1517 L.U.S.U./S.E.U.L. McEwen School of Architecture Francis Thorpe Extension/Poste 7212 L.U.A.P.S.A./A.P.A.P.U.L Institutional Planning/Planification

institutionnel Michael Malette Extension/Poste 4285

L.U.F.A./A.P.U.L. Psychology/Psychologie

Linda St-Pierre Extension/Poste 4127

L.U.F.A./A.P.U.L. McEwen School of Architecture

Thomas Strickland Extension/Poste L.U.F.A./A.P.U.L. Human Kinetics/Sciences activité physique Robyn Gorham Ext./Poste 3737

Lab Safety Committee/ Forensic Sciences Comité de la sécurité en laboratoire Extension/Poste 4117 Michele Bobyn Facility Servcies Safety Committee/ Facility Services/Service des installations Comité de la sécurité des service Extension/Poste des installations Joel Dube Living with Lakes Safety Committee/ Living with Lakes Comité de la sécurité pour Extension/Poste 4150 Living with Lakes Nathan Basiliko

G.T.A. /A.E.D. Graduate Teaching Assistants CUPE 5011/Assistants Alain Boulay d’enseignement diplômé SCFP 5011

MMAANNAAGGEEMMEENNTT RREEPPRREESSEENNTTAATTIIVVEESS//RREEPPRRÉÉSSEENNTTAANNTTSS AADDMMIINNIISSTTRRAATTIIFFSS TBD (Co-Chair / Co-présidente)

Gail Cowper Benoit Occupational Health and Safety/Santé et sécurité (Certified Member/Membre certifié) au travail - Extension/Poste 3061

Ray Coutu Director, Procurement and Risk Extension / Poste 1555 Jean Paul Cholette (Certified Member/Membre certifié) Physical Plant/Édifice de l’entretien Extension/Poste 1503

Lyne Rivet Health and Wellness/Santé et bien-être (Certified Member/Membre certifié) Extension/Poste 1055

Nicole St. Marseille Campus Safety Extension/Poste 1533

JHSC MEMBERS –April 5, 2018

APPENDIX C: Lab Safety Committee Terms of Reference

Mandate Laurentian University’s Lab Safety Committee is authorized to oversee the University’s Lab Safety

Program, provide policy direction and make recommendations to the Vice President, Research, for

all matters pertaining to research and teaching in a laboratory setting. This committee will be

responsible for reviewing the operational safety of both teaching and research laboratories at the

University and for recommending policies and procedures to improve health and safety in these

areas. It is intended to provide a mechanism whereby knowledgeable input from laboratory

practitioners and others is received, reviewed and utilized to advise the Vice President, Research, on

health and safety matters specific to laboratories and the environment.

Terms of Reference 1. Deals with all matters related to lab safety, including biohazards, chemical hazards,

radioactive materials and general lab safety.

2. To assess the impact of new and existing health and safety policies and procedures.

3. To monitor and promote compliance with the established policies and procedures as set out

in the most current versions of the Laboratory Safety Manual, Biosafety Program and the

Radiation Safety Program.

4. Conduct on a regular basis, (inspections will be scheduled monthly) lab inspection visits to

enhance safety awareness and compliance on campus. Problems and issues will be

immediately reported to the respective Dean, and the reports will be copied to the Joint

Health and Safety Committee (JHSC).

5. To have specific responsibility to develop and recommend policies, standards and general

direction for the safe storage, use, handling and disposal of hazardous materials in

laboratories within the context of the Occupational Health and Safety Act and Regulations.

6. To review, recommend and act as an expert resource for laboratory safety education and

training programs at Laurentian. Ensure that students (including undergraduate, graduates

students, teaching assistants) and staff are well trained, in function of the current policies of

the University.

7. To collaborate with deans, directors and/or chairs with respect to the appropriate institutional

occupational health and safety programs required to achieve the outcomes stated above.

Compliance and Conformance:

1. Suspends permits (Biosafety or Radiation safety) in cases of non-compliance or in cases of

emergencies involving loss or potential loss of containment;

2. Monitors certification and re-certification of laboratories with biohazards or radiation;

3. Monitors movement of biohazardous and radioactive materials within the University and for

compliance with the Transportation of Dangerous Goods Regulations when shipping or

receiving biohazardous materials;

4. Reviews summary results of external and internal inspections and recommends appropriate

action;

Reporting

1. Report problems or violations of the lab safety program, radiation safety program or

biosafety program to the respective Dean.

2. Reports to the Vice President, Research, substantial problems or violations of guidelines,

and significant accidents or illnesses;

3. Provides an annual report of its activities in the previous year and compliance status to the

Vice President, Research.

4. Provides a copy of all minutes and related documents to the JHSC.

Membership

Voting:

All members are appointed by the appropriate Department. Membership will be reviewed every two

years. When deemed necessary for specific expertise ad hoc consultants will be brought in.

The committee membership shall consist of:

1. Appointed member from the following departments: Biology, Chemistry, Earth Science,

Engineering, Forensic, Human Kinetics, Neuroscience, and Physics.

2. Appointed member who normally works with biohazardous material.

3. Appointed member who normally works with radioactive material.

4. Health and Safety Specialist, Biosafety Officer (BSO) and Radiation Safety Officer (RSO)

5. Manager, Research Services

6. Manager, Risk Management Office.

7. A Graduate Student Representative selected by the GSA.

All duly appointed members have voting privileges. Resource persons are non-voting members of

the committee.

Chair

1. The chair shall be an appointed member, nominated and elected by the members for a two

year term.

2. The chair does not normally vote, except to break a tie.

3. The chair shall represent this committee on the Joint Health and Safety Committee.

Secretariat

The Health and Safety Specialist shall act as secretary.

The secretary shall be responsible for:

1. Issuing notices of meetings after consultation with the chair;

2. Recording minutes of the meetings and related correspondence;

3. Circulating meeting minutes to the members and to the Joint Health and Safety Committee;

and

4. Maintaining all lab safety committee documentation.

Quorum

For voting purposes, at least four voting members must be present.

MEETINGS The committee shall meet quarterly. The chair may call emergency meetings.

APPENDIX D: Biosafety Risk Assessment Form PLEASE TYPE OR PRINT CLEARLY

1. Course Information

Title

Number Section(s) Start Date: Room Number:

Lab Activities

2. Contact Information

Supervisor Phone No.

Position Email:

Alternate Contact Phone No.

Position Email

3. Hazard Inventory and Risk Level Please review all categories and check ALL appropriate equipment/agents or activities and

estimated risk level where indicated.

3.1 Biohazards

YES NO

BioSafety Containment Level Approval

Level 1

Level 2

None required

In Progress

3.2 Other Hazards

YES NO HAZARD RISK LEVEL

Low Moderate Significant

Chemical Agents

Sharps

Temperature Extremes (<4C or >35C)

Field Trips: Specify

Equipment : Specify (eg. Autoclave,

centrifuge)

4. Hazard Control Program Identify hazard control programs and procedures that would be applicable and additional

requirements for specific projects. Provide attachment if space is insufficient.

4.1 Standard Operating Procedures (SOPs)

None required

Laboratory Manual Developed for the project/course

YES

NO

4.2 Personal Protection Equipment (PPE) required for the project/course

None required

Eye/Face

Hand/Skin

Foot

Head

Respiratory

Hearing

Temperature

Body/Clothing

Other __________

4.3 Permit/Special Licensing or Registration Requirement for the

project/course

Collection Permit Animal Care Certificate Other

Have application for permits been submitted:

Yes No

If no, state estimated date of application: _______________________________

4.4 Hazard Communication

None required

Do all the chemicals and bacteria being used for this course have up-to date (<3 years) MSDS available?

Yes No

If no, when will they be available _____________________________________

Where will they be located __________________________________________

4.5 Emergency Protocols and Equipment

Emergency procedure (spill, fire, injury, etc.) posted in laboratory?

Yes No N/A

Hazard Control Training

None required See Attachment

Regular Laboratory Meetings

Weekly

Monthly

As Required

N/A

4.6 Available Emergency Equipment

N/A

Eyewash

First Aid Kit

Sharps

Shower

Fire Extinguisher

Spill Control

Emergency Light

Other

of 39

5. Risk Assessment Form Completed By:

Signature: ___________________________________________ Date:

6. Supervisor Confirmation I confirm that the information contained in this Risk Assessment is accurate to the best of my

knowledge.

Signature: ___________________________________________ Date:

FORWARD FULLY COMPLETED FORM TO THE BIOSAFETY OFFICER

of 39

APPENDIX E: Biosecurity Plan

Biosecurity Plan [Name of PI] Date Approved Initial Date

Supervisor Revision Date

(signature)

Responsible Official

(signature)

Rooms Covered

[Enter text here as, Bldg / Room / Use ]

Scope

The Canadian Biosafety Standards requires all facilities which handle infectious agents to have a Biosecurity plan in place. Biosecurity plans are implemented to prevent the theft, misuse or intentional release of pathogens. This Biosecurity Plan specifies security requirements for working with bio hazardous materials. The main components of the biosecurity plan include: physical protection, personnel suitability/reliability, biohazard accountability, and incident and emergency response. All researchers/faculty need to have biosafety approval prior to working with bio hazardous materials. All applications are reviewed by the Biosafety Committee to determine whether the proposed handling of bio hazardous materials meets the Human Pathogen and Toxins Act and the Canadian Biosafety Standards, and to assess the containment level and biosecurity risk.

All staff working with bio hazardous materials must follow this Biosecurity Plan.

Access During Work Hours [ ] Door Locked at all times. [ ] Card key access to labs. [ ] Card key access to building/wing. [ ] Door unlocked when lab occupied.

of 39

Access Outside of Work Hours

[ ] Door locked. [ ] Card key access to labs. [ ] Card key access to building/wing. [ ] Monitored by security camera.

Storage

[ ] Fridges, freezers and liquid nitrogen Dewars which are located in shared room are locked if they contain bio hazardous materials of risk group 2 or higher [ ] Only trained and designated laboratory staff have access to locked freezers, fridges, and nitrogen Dewars containing bio hazardous material.

Personnel Access

[ ] Access to labs is restricted to authorized lab occupants, maintenance and janitorial staff and escorted visitors. [ ] All individuals must have biosafety training appropriate for the biosafety level. [ ] Biosecurity training is mandatory for all students and staff working in labs that contain bio hazardous materials. [ ] Visitors may enter a lab only if they are given permission by the supervisor and are escorted by a trained lab occupant.

Biohazard Accountability

[ ] An inventory of all containment level 2 bio hazardous materials is maintained from acquisition through disposal. [ ] The inventory includes the type, quantity and location of bio hazardous material and is updated annually or as it changes. [ ] All bio hazardous materials and storage areas are clearly labeled. [ ] A record is maintained of the inactivation and disposal of material after use. [ ] Loss, theft, or misuse of a bio hazardous material is reported to the supervisor and to the Occupational Health and Safety Office at ext 3061. Security incidents include breach of containment, unauthorized removal of pathogens, and unauthorized personnel in restricted areas.

of 39

Emergency Contact Information

Principle Investigator Phone / Email: Responsible Official Phone / Email: Biosafety Office: 705-675-1151 ext 3061 Local Security: 705-673-6562 or 705-675-1151 ext 6562

Signature of ALL Lab Members By signing this document, you affirm that you have read, understood and agreed to adhere to the requirements set out in this biosecurity plan.

Name Signature Date

of 39

APPENDIX F: Biosafety Permit Application

Biosafety Program - Laurentian University Office Files...3.3.6 Biosafety Program 3.3.7 Laboratory...

Documents

Transcript of Biosafety Program - Laurentian University Office Files...3.3.6 Biosafety Program 3.3.7 Laboratory...