Biological Safety

Biological Safety requirements are outlined in the Biological Safety Manual. The Biological Safety Manual is reviewed by the Institutional Biosafety Committee (IBC) periodically. Work with human cells and other human derived materials is safely conducted using the guidance provided in the Bloodborne Pathogens and Exposure Control Plan.

The management of biological waste is also a part of biological safety. Some biological waste, such as sharps containers, is managed by using the Biological Waste Pickup Request. Waste that is managed in the lab (by autoclaving or bleaching) may need to be recorded on a log. The Biological Safety Manual gives more details and training is available to explain the different types of biological waste.

Biological Safety Manual

The purpose of this manual is to provide guidance for personnel on how to perform work with biological
materials safely. All research and teaching laboratories that use biological materials are expected to be
in compliance with this manual in the areas where it applies. Where the guidance provided in this
manual is not used, written documentation should be given showing that the procedure or arrangement
used in lieu of the guidance given in this manual will provide a situation that is either as safe or safer
than the guidance given in this manual.

The primary sources for the regulations and guidelines that apply to biological safety are the US Center
for Disease Control’s (CDC) Biosafety in Microbiological and Biomedical Laboratories (BMBL) 5th Edition
and the National Institute of Health (NIH) Guidelines for Research Involving Recombinant or Synthetic
Nucleic Acid Molecules. There is also limited application of both the United States Department of
Agriculture (USDA) and the Food and Drug Administration (FDA) regulations. These authorities are cited
where appropriate.

Arkansas State University is required by NIH guidelines to have an Institutional Biosafety Committee
(IBC). The IBC is composed of faculty and staff from various departments at the university. The IBC
oversees all research projects that involve recombinant DNA and all research projects where pathogenic
microorganisms are used. The IBC has also reviewed and approved this manual; any changes to the
manual are made available to the IBC for review prior to their implementation.

Biological Safety Manual

Contents

Chapter 1 Guidance, Regulations and Roles of Key Personnel 
1.1 Introduction
1.2 Guidance
1.3 Regulations
1.4 Roles of Key Personnel
1.4.1 Institutional Biosafety Committee (IBC)
1.4.2 Biological Safety Officer
1.4.3 Principal Investigator 
Chapter 2 Biological Risk Assessment
2.1 Introduction
2.2 Hazardous Characteristics of Agents 
2.2.1 Principal Hazardous Characteristics
2.2.2 Risk Groups 
2.2.3 Resources 
2.3 Risk Assessment for Human Cell Lines and Human-Derived Materials 
2.4 Risk Assessment for Other Agents 
Chapter 3- Principles of Biosafety 
3.1 Introduction
3.2 Engineering Controls 
3.3 Personal Protective Equipment 
3.4 Facility Construction and Design 
Chapter 4- Laboratory Biosafety Level Criteria 
4.1 Introduction 
4.2 Biosafety Level 1 
4.3 Biosafety Level 2 
4.4 Biosafety Level 3 
4.5 Biosafety Level 4 
4.6 Multi-User Research Labs 
Chapter 5- Vertebrate Animal Biosafety Level Criteria for Vivarium Research Facilities
Chapter 6- Select Agents/ Toxins and Principles of Laboratory Biosecurity 
Chapter 7- Medical Surveillance 
Chapter 8 Emergencies and Reporting 
8.1 Spills 
8.1.1 General 
8.1.2 Spills outside of a containment device 
8.1.3 Spills inside of a Biological Safety Cabinet (BSC) 
8.1.4 Spills in a centrifuge 
8.1.5 Biological/Radioactive emergencies/spills
8.2 Exposure to Biohazardous Agents or Material 
8.3 Security incidents 
Chapter 9 Biohazardous Waste Management
9.1 Scope 
9.2 Biohazardous Waste Definition 
9.3 Responsibilities
9.3.1 Principal Investigator or Faculty in Charge of Lab
9.3.2 Biological Safety Officer (BSO) 
9.3.3 Environmental Health and Safety (EHS) 
9.4 Disinfection 
9.5 Treatment, Storage and Disposal 
9.5.1 General Storage and Disposal Methods for Different Types of Waste 
9.5.2 Chemical Treatment Standards 
9.5.3 Autoclave Standards 
9.5.4 Logging 
Appendix A Biological Safety Cabinets 
Appendix B Shipping of Biohazardous Materials 
Appendix C Transport of Biohazardous Material 
Appendix D Use of Human, Non-human Primate and other Mammalian Cells and Tissues 
Appendix E Guidelines for Work with Toxins of Biological Origin
Appendix F NIH Oversight of Research Involving Recombinant DNA 
Appendix G Recombinant DNA Experiments Involving Plants 
Appendix H Autoclaves

Biological Safety Manual

Chapter 1 Guidance, Regulations and Roles of Key Personnel

1.1 Introduction

This Biosafety Manual (BSM) provides a review of pertinent federal guidance and regulations, state
regulations, information about safe work practices, safety equipment and personal protective
equipment, and specific guidance for research with recombinant DNA (rDNA). Arkansas State’s Biological
Safety Program is based on the premise that every member of the research community shares the
responsibility for safety.

1.2 Guidance

US Center for Disease Control’s (CDC) Biosafety in Microbiological and Biomedical Laboratories (BMBL)
5th Edition is the key guidance document for Biosafety. Although BMBL5 only recommends practices
(“We wish to emphasize that the 5th edition of the BMBL remains an advisory document recommending
best practices for the safe conduct of work in biomedical and clinical laboratories from a biosafety
perspective, and is not intended as a regulatory document though we recognize that it will be used that
way by some.” BMBL5 Forward), unless otherwise specifically stated herein, compliance with all BMBL5
recommendations is mandatory for all laboratory biological activities (research, teaching, public
service).

Biosafety in Microbiological and Biomedical Laboratories (BMBL) 6th Edition | CDC Laboratories

NIH Guidelines is also a key guidance document for this manual. Whereas BMBL5 recommends
practices, NIH Guidelines specifies practices; “The purpose of the NIH Guidelines is to specify
practices….” (NIH Guidelines Section I-A. Purpose). Although these NIH Guidelines closely follow the
recommendations of BMBL6, in some cases the guidelines are more restrictive. In certain cases, this
manual will adopt the more restrictive practices of the Guidelines, regardless of whether rDNA is
involved. The advent of multi-PI labs precludes separate consideration of BMBL6 and the Guidelines. In
such cases, the specific guideline will be referenced and explained.

NIH Guidelines for Research Involving Recombinant or Synthetic Nucleic Acid Molecules (NIH Guidelines)

1.3 Regulations

Ark. Code Ann. § 20-7-109 and Ark. Code Ann. §§ 20-32-101 - 112 Rules and Regulations Pertaining to
the Management of Medical Waste from Generators and Health Care Related Facilities governs
management of biological waste.


Medical_Waste_Regs_2016_FINAL.pdf

US Department of Transportation’s 49CFR Subchapter C Hazardous Materials Regulations governs
shipment of infectious (biohazardous) materials.

eCFR :: 49 CFR Chapter I Subchapter C -- Hazardous Materials Regulations

1.4 Roles of Key Personnel

1.4.1 Institutional Biosafety Committee (IBC)

1.4.2 Biological Safety Officer

The Biological Safety Officer (BSO) should:

1.4.3 Principal Investigator

The Principal Investigator (PI) should:

 

Biological Safety Manual

Chapter 2 Biological Risk Assessment

2.1 Introduction

Risk assessment is a process used to identify the hazardous characteristics of a known infectious or potentially infectious agent or material, the activities that can result in a person’s exposure to an agent, the likelihood that such exposure will cause a laboratory acquired infection (LAI), and the probable consequences of such an infection. The information identified by risk assessment will provide a guide for the selection of appropriate biosafety levels and microbiological practices, safety equipment, and facility
safeguards that can prevent LAIs. The primary factors to consider in risk assessment and selection of precautions fall into two broad categories: agent hazards and laboratory procedure hazards. The agent summary statements contained in BMBL6 identify the primary agent and procedure hazards for specific pathogens and recommend precautions for their control. A review of the summary statement for a specific pathogen is the starting point for assessment of the risks of working with that agent and those
for a similar agent.

Biosafety in Microbiological and Biomedical Laboratories (BMBL) 6th Edition | CDC Laboratories

2.2 Hazardous Characteristics of Agents

2.2.1 Principal Hazardous Characteristics

The principal hazardous characteristics of an agent are:

2.2.2 Risk Groups

The NIH Guidelines assigns human etiological agents into four risk groups on the basis of hazard. Agents are classified into four Risk Groups (RGs) according to their relative pathogenicity for healthy adult humans by the following criteria:

2.2.3 Resources

2.4 Risk Assessment of Other Agents

The end product of risk assessment is the assignment of an appropriate biosafety level (BSL) for an experiment. BSLs will be discussed in detail in Chapter 4. The initial risk assessment from the preceding resources should be followed by a thorough consideration of how the agent is to be manipulated. Agent factors to be considered in determining the BSL include:

Any strain that is known to be more hazardous than the parent (wild-type) strain should be considered for handling at a higher BSL. Certain attenuated strains or strains that have been demonstrated to have irreversibly lost known virulence factors may qualify for a reduction of the containment level compared to the RG assigned to the parent strain. 

Biological Safety Manual

Chapter 3 - Principles of Biosafety

3.1 Introduction
A fundamental objective of any biosafety program is the containment of potentially harmful
biological agents. The term “containment” is used in describing safe methods, facilities and
equipment for managing infectious materials in the laboratory environment where they are being
handled or maintained. The purpose of containment is to reduce or eliminate exposure of
laboratory workers, other persons, and the outside environment to potentially hazardous agents.
The most important element of containment is strict adherence to standard microbiological
practices and techniques. Knowledge of standard microbiological practices and techniques is gained
through a combination of training and experience.

3.2 Engineering Controls
Engineering controls eliminate or reduce the exposure of individuals to hazards in the laboratory
through the use of specialized equipment. In most cases, engineering controls will be the primary barrier
between hazardous materials and the individual. Engineering controls include:
 Biological safety cabinets (BSCs) (discussed in Appendix A)
 Other enclosures
 Safety centrifuge cups
 Retractable needles
3.3 Personal Protective Equipment
Personal protective equipment (PPE) is equipment that the individual wears to protect them from
exposure to hazards in the laboratory. PPE is generally intended to be a secondary barrier meaning that
it is to be used in conjunction with engineering controls to protect the user. PPE may be used a primarybarrier when engineering controls are not possible or feasible.PPE worn should be based on the hazard
present and can include:
 Gloves
 Safety glasses or splash goggles
 Lab coat
 Gown
 Shoe covers
 Boots
 Respirator (includes dust masks)
 Face shield
3.4 Facility Construction and Design
The design and construction of the facility provides a secondary barrier to protect persons outside the
laboratory. PI’s are responsible for providing facilities commensurate with the laboratory’s function and
the recommended biosafety level for the agents being manipulated. The recommended secondary
barrier(s) will depend upon the risk of transmission of specific agents. For example, the exposure risks
for most laboratory work in BSL-1 and BSL-2 facilities will be direct contact with the agents, or
inadvertent contact exposures through contaminated work environments. Secondary barriers in these
laboratories may include separation of the laboratory work area from public access, availability of a
decontamination facility (e.g., autoclave) and hand washing facilities.



Biological Safety Manual

Chapter 4 - Laboratory Biosafety Level Criteria

4.1 Introduction
Four biosafety levels (BSLs) are described in BMBL5; each consists of a combination of laboratory
practices and techniques, safety equipment, and laboratory facilities. Each combination is specifically
appropriate for the operations being performed, the documented or suspected routes of transmission of
the infectious agents, and the laboratory function or activity.
The BSLs described in BMBL5 should be differentiated from Risk Groups, as described in the NIH
Guidelines and the World Health Organization Laboratory Biosafety Manual. Risk groups are the result
of a classification of microbiological agents based on their association with, and resulting severity of,
disease in humans. The risk group of an agent should be one factor considered in association with mode
of transmission, procedural protocols, experience of staff, and other factors in determining the BSL in
which the work will be conducted.
The recommended biosafety level(s) for the organisms in BMBL5 Section VIII (Agent Summary
Statements) represent those conditions under which the agent ordinarily can be safely handled. Not all
of the organisms capable of causing disease are included in Section VIII; the other resources listed in
Chapter 2 of this manual must be utilized to perform risk assessments for agents not listed in SectionVIII. Generally, work with known agents should be conducted at the biosafety level recommended in
Section VIII.
When information is available to suggest that virulence, pathogenicity, antibiotic resistance patterns,
vaccine and treatment availability, or other factors are significantly altered, more (or less) stringent
practices may be specified. Often an increased volume or a high concentration of agent may require
additional containment practices.
4.2 Biosafety Level 1
Biosafety level 1 practices, safety equipment, and facility design and construction are appropriate for
undergraduate training and teaching laboratories, and for other laboratories in which work is done with
defined and characterized strains of viable microorganisms not known to consistently cause disease in
healthy adult humans.
Bacillus subtilis, Nigeria gruberi, infectious canine hepatitis virus, and exempt organisms under the NIH
Guidelines are representative of microorganisms meeting these criteria. Many agents not ordinarily
associated with disease processes in humans are, however, opportunistic pathogens and may cause
infection in the young, the aged, and immunodeficient or immunosuppressed individuals. Vaccine
strains that have undergone multiple in vivo passages should not be considered avirulent simply
because they are vaccine strains.
BSL-1 represents a basic level of containment that relies on standard microbiological practices with no
special primary or secondary barriers recommended, other than a sink for hand washing.
4.3 Biosafety Level 2
Biosafety level 2 practices, equipment, and facility design and construction are applicable to clinical,
diagnostic, teaching, and other laboratories in which work is done with the broad spectrum of
indigenous moderate-risk agents that are present in the community and associated with human disease
of varying severity. With good microbiological techniques, these agents can be used safely in activities
conducted on the open bench, provided the potential for producing splashes or aerosols is low.
Hepatitis B virus, HIV, Salmonella, and Toxoplasma are representative of microorganisms assigned to
this containment level. BSL-2 is appropriate when work is done with any human-derived blood, body
fluids, tissues, or primary human cell lines where the presence of an infectious agent may be unknown.
(Laboratory personnel working with human- derived materials should refer to the OSHA Bloodborne
Pathogen Standard for specific required precautions).
Primary hazards to personnel working with these agents relate to accidental percutaneous or mucous
membrane exposures, or ingestion of infectious materials. Extreme caution should be taken with
contaminated needles or sharp instruments. Even though organisms routinely manipulated at BSL-2 are
not known to be transmissible by the aerosol route, procedures with aerosol or high splash potential
that may increase the risk of such personnel exposure must be conducted in primary containment
equipment, or in devices such as a BSC or safety centrifuge cups.

Personal protective equipment should be used as appropriate, such as splash shields, face protection,
gowns, and gloves. Secondary barriers, such as hand washing sinks and waste decontamination facilities,
must be available to reduce potential environmental contamination.
4.4 Biosafety Level 3
Biosafety level 3 practices, safety equipment, and facility design and construction are applicable to
clinical, diagnostic, teaching, research, or production facilities in which work is done with indigenous or
exotic agents with a potential for respiratory transmission, and which may cause serious and potentially
lethal infection.
Mycobacterium tuberculosis, St. Louis encephalitis virus, and Coxiella burnetii are representative of the
microorganisms assigned to this level. Primary hazards to personnel working with these agents relate
to autoinoculation, ingestion, and exposure to infectious aerosols.
At BSL-3, more emphasis is placed on primary and secondary barriers to protect personnel in contiguous
areas, the community, and the environment from exposure to potentially infectious aerosols. For
example, all laboratory manipulations should be performed in a BSC or other enclosed equipment, such
as a gas-tight aerosol generation chamber. Secondary barriers for this level include controlled access to
the laboratory and ventilation requirements that minimize the release of infectious aerosols from the
laboratory.
There are currently no BSL-3 activities occurring at Arkansas State University.
4.5 Biosafety Level 4
Biosafety level 4 is beyond the scope of this manual. There are currently no BSL-4 activities occurring at
Arkansas State University.
4.6 Multi-User Research Labs
The advent of large open labs and lab suites creates problems for separation of BSL1 and BSL2 areas and
activities. The following NIH Guidelines, which shall apply to all biological activities at Arkansas State,
make a multi-PI lab problematic.
For BSL1, Access to the laboratory is limited or restricted at the discretion of the Principal Investigator
when experiments are in progress [Appendix G-II-A-1-a]. For BSL2, Access to the laboratory is limited or
restricted by the Principal Investigator when experiments are in progress [Appendix G-II-B-1-a]. For
BSL2, Experiments of lesser biohazard potential can be conducted concurrently in carefully demarcated
areas of the same laboratory [Appendix G-II-B-1-h].
Any research group working with agents that are known or potential biohazards shall have an
emergency plan that describes the procedures to be followed if an accident contaminates personnel or
the environment. The Principal Investigator shall ensure that everyone in the laboratory is familiar with
both the potential hazards of the work and the emergency plan” [Appendix G-I. Standard Practices and
Training].
The Principal Investigator establishes policies and procedures whereby only persons who have been
advised of the potential hazard and meet any specific entry requirements (e.g., immunization) may enter the laboratory or animal rooms [Appendix G-II-B-2-c].
For BSL2, Laboratory coats, gowns, smocks, or uniforms are worn while in the laboratory. Before exiting
the laboratory for non-laboratory areas (e.g., cafeteria, library, administrative offices), this protective
clothing is removed and left in the laboratory or covered with a clean coat not used in the laboratory
[Appendix G-II-B-2f].
The BSO shall work with the occupants of each multi-PI lab to determine the most effective way of
complying with the cited Guidelines for each lab. The default solution is to designate the entire lab BSL2,
with clearly demarcated BSL1 section(s) as required. Note that BSL2 waste must be kept in the BSL2 area
until decontaminated. Also, all Risk Group 2 agents must remain secure (under the control of the
researcher using the agent only). The highlighted training requirement above will be met by maintaining
a notebook containing a Pathogen Safety Data Sheet (PSDS) for each RG2 agent in use.

Biological Safety Manual

Chapter 5 - Vertebrate Animal Biosafety Level Criteria for Vivarium Research Facilities

BMBL5 provides guidance for the use of experimentally infected animals housed in indoor research
facilities (e.g., vivaria), and is also useful in the maintenance of laboratory animals that may naturally
harbor zoonotic infectious agents. Laboratory animal facilities are a special type of laboratory. As a
general principle, the biosafety level (facilities, practices, and operational requirements) recommended
for working with infectious agents in vivo and in vitro are comparable.
The animal room can present unique problems. In the animal room, the activities of the animals
themselves can present unique hazards not found in standard microbiological laboratories. Animals may
generate aerosols, they may bite and scratch, and they may be infected with a zoonotic agent. The coapplication of Biosafety Levels and the Animal Biosafety Levels are determined by a protocol-driven risk
assessment.
Facilities for laboratory animals used in studies of infectious or non-infectious disease should be
physically separate from other activities such as animal production and quarantine, clinical laboratories,
and especially from facilities providing patient care. Traffic flow that will minimize the risk of cross
contamination should be incorporated into the facility design.
The recommendations detailed in BMBL5 Section V describe four combinations of practices, safety
equipment, and facilities for experiments with animals involved in infectious disease research and other
studies that may require containment. These four combinations, designated Animal Biosafety Levels
(ABSL) 1-4, provide increasing levels of protection to personnel and to the environment, and are
recommended as minimal standards for activities involving infected laboratory animals. The four ABSLs
describe animal facilities and practices applicable to work with animals infected with agents assigned to
Biosafety Levels 1-4, respectively. Investigators that are inexperienced in conducting these types of
experiments should seek help in designing their experiments from individuals who are experienced in
this special work.
In addition to the animal biosafety levels described in Section V, the USDA has developed facility
parameters and work practices for handling agents of agricultural significance. Appendix D of BMBL5
includes a discussion on Animal Biosafety Level 3 Agriculture (BSL-3-Ag). USDA requirements are unique
to agriculture because of the necessity to protect the environment from pathogens of economic or environmental impact. Appendix D also describes some of the enhancements beyond BSL/ABSL-3 that
may be required by USDA-APHIS when working in the laboratory or vivarium with certain veterinary
agents of concern.
Care of research animals is the responsibility of the Institutional Animal Care and Use Committee. 

Biological Safety Manual

Chapter 6 - Select Agents/toxins and Principles of laboratory Biosecurity

Select Agents are federally regulated agents that have potential use in biological warfare. Health and
Human Services (HHS) regulates select agents targeting humans, the United States Department of
Agriculture (USDA) regulates select agents targeting animals, and the USDA Plant Protection and
Quarantine (PPQ) regulates select agents targeting plants. Before possessing, using, sending, or
receiving select agents, the institution and Principal Investigator must register with CDC, APHIS, and/or
USDA to receive official authorization for each individual requesting access to select agents.
Requirements include background checks on those authorized to access select agents, security plans and
inventories. Immediately notify EHS if you discover select agents in your laboratory that have not been
registered. View the Select Agent/Toxin List here:
https://www.selectagents.gov/SelectAgentsandToxinsList.html. Anyone desiring to work with these
materials must have security clearance to do so and have special security procedures in place for their
labs. Investigators wishing to work with any of these agents MUST contact Melissa Dooley, the EHS
Director, prior to doing so, and all security clearances and procedures must be in place prior to
requesting the Select Agents (note that requests for Select Agents MUST be placed by the Responsible
Official). Contact Melissa Dooley Phone: 870-972-3644 E-mail: mdooley@astate.edu for assistance
with Select Agent requirements.
The term “biosecurity” has multiple definitions. In the animal industry, the term biosecurity relates to
the protection of an animal colony from microbial contamination. In some countries, the term
biosecurity is used in place of the term biosafety. For the purposes of this section the term “biosecurity”
will refer to the protection of microbial agents from loss, theft, diversion or intentional misuse. This is
consistent with current WHO and American Biological Safety Association (ABSA) usage of this term.
Biosafety and biosecurity programs share common components. Both are based upon risk assessment
and management methodology; personnel expertise and responsibility; control and accountability for
research materials including microorganisms and culture stocks; access control elements; material
transfer documentation; training; emergency planning; and program management. Biosafety and
biosecurity program risk assessments are performed to determine the appropriate levels of controls
within each program. Biosafety looks at appropriate laboratory procedures and practices necessary to
prevent exposures and occupationally-acquired infections, while biosecurity addresses procedures and
practices to ensure that biological materials and relevant sensitive information remain secure.

Biological Safety Manual

Chapter 7 - Medical Surveillance

According to the BMBL, “Laboratory personnel must be provided medical surveillance, as appropriate,
and offered immunization for agents handled or potential present in the laboratory.” Medical surveillance and vaccinations should be considered when infectious agents are present in the lab at the
recommendation of the IBC. Work with human cells requires offer of vaccination to lab workers. For
more details, consult the Arkansas State University Exposure Control Plan.

Biological Safety Manual

Chapter 8 - Emergencies and Reporting

8.1 Spills
8.1.1 General
In general, most spills can be effectively handled by researchers and a spill kit should be available in any
laboratory area where biohazardous materials are used or stored. The following are recommended
procedures for evaluating and handling a spill:
 An appropriate disinfectant that works against the BSL-2 agents of concern must be used.
 Allow sufficient contact time for the disinfectant to work. Follow manufacturer’s directions.
 Procedures vary with location depending upon if inside or outside of a containment device.
 Cleaning spills requires personal protective equipment (PPE) including a lab coat or gown, and
gloves. A face shield, shoe covers or a respirator may be required.
 All spills must be reported to the Laboratory Supervisor and/or Principal Investigator. Contact
the Biosafety Safety Officer (mdooley@astate.edu) for any questions about spill cleanup
procedures.
8.1.2 Spills outside of a containment device
If the spill is not inside of a Biological Safety Cabinet (BSC), Centrifuge, Refrigerator, Incubator, Freezer,
Lab instrument etc. follow this procedure:
 Close off spill area to traffic, and notify coworkers.
 If the spill may involve an aerosol, (e.g. event involving dropping material onto floor, high
mechanical force, a forceful expulsion of liquid) leave the room for 30 minutes to allow aerosols
to settle.
 Remove contaminated lab coat or clothing and wash exposed skin and put on clean gloves and
lab coat.
 Prepare enough volume of a 1:9 dilution of chlorine bleach or other approved disinfectant to
saturate the contaminated area. If dilution is not possible, undiluted household bleach can be
used. However, eye protection must be worn and care taken not to splash the bleach onto skin
or clothing.
 Contain the spill with paper towels or other absorbent material e.g. "bench kote", blue "diaper
pads"
 Flood the spill area with disinfectant. Leave on for 10 minutes.
 Push the absorbent material at the edge of the spill into the spill's center. Add more paper
towels as needed. If glass is present, do not use bare hands! Use tongs (large pieces) forceps(small pieces) followed by a dustpan to remove pieces. Place the paper towels and gloves in a
Zip-lock bag and discard bag in biohazard box (see Chapter 9). If contact with bleach occurs with
skin, mucous membranes or eyes, flush area with copious amounts of water.
 Wash hands thoroughly. Autoclave an overtly contaminated lab coat to prior to placing into
laboratory laundry bag.
 Report incident to supervisor and Principal Investigator.
8.1.3 Spills inside of a Biological Safety Cabinet (BSC)
If the spill is inside a biological safety cabinet, follow the following procedure:
 Leave BSC on.
 Put on gloves and lab coat and gather paper towels for cleaning.
 Prepare a fresh dilution of 1:9 bleach or approved disinfectant. Prepare enough solution to
cover the entire contaminated area. Always follow manufacturer’s directions. Do not use 70%
ethanol as it evaporates too quickly to allow adequate surface contact time.
 Flood the area with disinfectant solution and allow to remain in contact for required time:
 10% Bleach for 10 minutes; or, Cavicide (full strength) for 3 minutes; or, Beaucoup (diluted
according to manufacturer’s directions) for 10 minutes.
 Spray and or wipe down the cabinet interior and any items inside the BSC with a towel
dampened with disinfectant.
 Place the paper towels and gloves in a Zip-lock bag and discard bag in biohazard box (see
Chapter 9).
 Spills large enough to result in liquids flowing through the front or rear grilles require more
extensive decontamination; consult BSO immediately at (mdooley@astate.edu), for guidance. If
a spill such as this has occurred, do not turn the BSC off.
 Report incident to supervisor and Principal Investigator.
8.1.4 Spills in a centrifuge
Biohazardous spills in centrifuges can be quite difficult to disinfect. Some but not all centrifuges have
closed rotors, buckets or other carriers with leak proof lids, designed to contain spills and allow efficient,
safe emptying and decontamination. However, not all centrifuges are equipped with these containment
devices. A spill resulting from primary container breakage requires immediate suspension of use, PI
notification and assistance from the Biological Safety Officer.
If unusual sounds from a centrifuge suggest that breakage and a spill has occurred, or, if breakage and a
spill is discovered after the machine has stopped, wait at least 30 minutes after centrifuge has stopped
before opening. This will allow hazardous aerosols to settle in the centrifuge. Then, follow this
procedure:
 Don lab coat, gloves, and face shield prior to opening centrifuge and then open carefully to
assess the situation. Use of a respirator is recommended and double gloving is advisable if glass
tubes were used and broken.
 Attempt to determine if the spill is contained in a closed cup, bucket or tray carrier, or within a
closed rotor. If the spill is contained as described in (2), spray the exterior with disinfect and allow adequate
contact time. Take the carrier to the nearest BSC approved for use with this agent. NOTE: If a
BSC is not available or if the rotor cannot be removed, the centrifuge should remain closed. Post
a sign indicating "contaminated-do not use". Notify lab director and or PI and contact BSO at
(mdooley@astate.edu), for assistance.
 Obtain and place into the BSC containers suitable for holding tubes, broken glass or other
containers while cleaning centrifuge components.
 Carefully retrieve unbroken tubes, wipe outside with disinfectant, and place them into the other
empty container in the BSC, out of the way. The broken glass tube(s) must be removed with a
forceps or other instrument and immersed in a beaker of disinfectant solution for a time
appropriate to achieve disinfection. The pieces can then be disposed of in a sharps container.
 After proper decontamination, carriers, rotors etc. can be washed with a mild detergent
according to the manufacturer’s instructions.
 Thoroughly wipe the inside of the centrifuge chamber with disinfectant saturated towels. Allow
for adequate contact time before wiping up excess liquid. Place the paper towels and gloves in a
ziplock bag (if you do not have any on hand, contact EHS) and request pickup of the bag using
the EHS waste pickup form (See chapter 9).
8.1.5 Biological/Radioactive emergencies/spills
EHS must be notified and will assist in the cleanup of a biological/radioactive spill. Determine if anyone
has been contaminated, remove contaminated clothing and wash contaminated skin with soap and
water. Proceed with clean up as instructed by the Radiation Safety Officer (EHS). The infectious agent
will be neutralized first, taking care in choosing a disinfecting agent to avoid chemical incompatibility.
Chlorine compounds such as bleach must NOT be used to disinfect anything containing I-125 because
the chlorine will cause the volatilization of radioactive iodine.
8.2 Exposure to Biohazardous Agents or Material
An exposure is defined as: BSL-2 agent contact with broken skin, eyes, nose, mouth, other mucous
membranes, a percutaneous injury with a contaminated sharp, or contact with an infectious agent over
a large area of apparently intact skin. Individuals are encouraged to report any conditions that may
increase risk or consequences of a laboratory acquired infection (e.g. pregnancy, a medical condition
which compromises immunity) to their PI. In the event of exposure:
 If the exposure creates a medical emergency, go to the closest emergency medical center or call
911.
 Wash the area with soap and water or flush eyes, nose or mouth with large amounts of water for
15 minutes.
 Students not employed by the university must report to the Student Health Center during
business hours for personal exposures. During off hours, an outpatient facility may be used if
necessary.
 All exposures must be reported to the immediate supervisor and Principal Investigator. The
Principle Investigator is responsible for helping the employee in beginning the Workman’s
Compensation process and reporting the exposure. EHS personnel will instruct the supervisor and
the employee on what to do.
 Principal Investigators are responsible for reporting exposure incidents to Biosafety Officer. The Biosafety Officer will perform a follow-up investigation of the incident and report findings to
the Institutional Biosafety Committee (IBC).
8.3 Security incidents
Security incidents such as suspicious visitors, missing chemicals, or missing biological agents must be
promptly reported to the Principal Investigator. University Police should be notified. Principal
Investigators are responsible for reporting incidents to EHS. 

 

Biological Safety Manual

Chapter 9 - Biohazardous Waste Management

9.1 Scope
While this protocol is included as a part of the Biosafety Manual, it applies to all generator of medical
waste as defined by the regulation and this protocol at this university. The applicability is defined by the
Arkansas Department of Health (ADH) Rules and Regulations Pertaining to the Management of Medical
Waste from Generators and Health Care Related Facilities promulgated under the authority of Ark. Code
Ann. § 20-7-109 and Ark. Code Ann. § § 20-32-101 – 112.
9.2 Biohazardous Waste Definition
Medical waste (also known as biohazardous waste or infectious waste) is waste that requires
inactivation of the biological material in an approved manner prior to final disposal. It includes the
following:
 Pathological waste - all human unfixed tissues, organs and anatomical parts, other than intact
skin, which emanate from surgeries, obstetrical procedures, dental procedures, autopsies and
laboratories, including embalming waste Such waste shall be exclusive of bulk formaldehyde and
other preservative agents.
 Liquid or semi-liquid blood such as human blood, human blood components and/or products
made from human blood (e.g., serum, plasma) and other potentially infectious materials, to
include regulated human body fluids such as semen, vaginal secretions, cerebrospinal fluid,
pleural fluid, pericardial fluid, synovial fluid, peritoneal fluid, amniotic fluid, saliva in dental
procedures, any body fluid that is visibly contaminated with blood, and all body fluids where it is
difficult or impossible to differentiate between body fluids, can be discharged into the collection
system of a publicly owned treatment works (POTW) within the generating facility. Breast milk,
urine, and feces are not considered medical waste and can also be discharged into the (POTW).
 Contaminated items to include dressings, bandages, packing, gauze, sponges, wipes, personal
protective equipment, cotton rolls and balls, etc., which cannot be laundered or disinfected and from which blood, blood components, or regulated body fluids drip freely, or that would release
blood or regulated body fluids in a liquid or semi-liquid state if compressed or are caked with
dried blood or regulated body fluids and all capable of releasing these materials during handling,
not to include feminine products, enema bags, used condoms, or diapers.
 Contaminated disposable, single-use gloves such as surgical or examination gloves
shall not be washed or decontaminated for reuse and are to be handled as a
contaminated item.
 Protective coverings such as plastic wrap and aluminum foil used to cover
equipment and environmental surfaces when removed following their
contamination are considered a contaminated item.
 All patient care items from hospital isolation rooms and end-stage renal dialysis
units, or from patients with communicable diseases, which cannot be laundered
and which are contaminated with regulated body fluids or blood or potential
infectious material, must be considered a contaminated item.
 Biological waste and discarded materials contaminated with blood, excretion,
exudates, or secretions from isolated animals known, or suspected, to be infected
with communicable diseases.
 Microbiological waste which includes, but is not limited to, cells and tissue cultures, culture
medium or other solutions and stocks of infectious agents, organ cultures, culture dishes,
devices used to transfer, inoculate and mix cultures, paper and cloth that has come in contact
with specimens or cultures and discarded live or attenuated vaccines.
 Contaminated sharps which include, but is not limited to, any contaminated object that can
penetrate the skin, e.g., hypodermic needles, intravenous tubing with needles attached,
syringes with attached needles, razor blades used in surgery, scalpel blades, Pasteur pipettes,
capillary tubes, broken glass from laboratories, and dental wires. Potentially breakable
container(s) of blood, regulated body fluid, microbiological waste, or infectious material must be
treated as contaminated sharps when disposed of. Sharps that have been used in human or
animal patient care, treatment or for other medical procedures are included. Any waste
produced in the course of physically altering a human being or animal including tattooing, ear
piercing, or any other process where a foreign object is used to cut or pierce the skin. All waste
generated in this manner meeting the definition of sharps must be handled accordingly.
 Veterinary waste to include any and all animal related waste (carcasses, body parts, bulk blood
and blood products, bedding of animals, etc.) which meets the definition of any of the five
categories delineated above and has been or is suspected to have been exposed to a zoonotic
disease or pathogens known to cause human disease, or which has been exposed to human
pathogens in research or the production of biological, must be handled as medical waste. All
contaminated sharps and microbiological waste must be handled as medical waste.
 Trace contaminated chemotherapy waste that can be treated as medical/infectious waste. Bulk
wastes such as full expired vials of chemotherapy drugs are considered to be chemical waste
NOT biological waste and should be managed accordingly. Trace contaminated chemotherapy
waste includes: Masks
 Empty drug vials
 Gloves
 Gowns
 IV tubing
 Empty IV bags/bottles and
 Spill clean-up materials.
 Spill/clean-up material collected during or resulting from the clean-up of a spill of regulated
medical waste.
 Crime scene/accident/trauma clean-up waste generated by individuals or commercial entities
hired to clean crime scenes or accidents that are saturated with human blood, sharps, or sharp
objects contaminated with human blood.
 Recombinant DNA. All contaminated liquid, solid, carcasses, and animal wastes from research
activities involving RG-2 agents requiring BSL-2 and ABSL-2 containment. All contaminated
liquid, solid, carcasses, and animal wastes from research activities involving RG-3 agents
requiring BSL-3 and ABSL-3 containment. NOTE: Although RG1-associated DNA is not included
in the definition of medical waste; all materials that have been in contact with recombinant
DNA must be decontaminated prior to disposal in the sewer or trash. These items are not
subject to the logging requirements described for autoclaves and chemical disinfection but
they must still be rendered biologically inactive. This includes recombinant plants.
 Additional wastes may be added at the discretion of the Institutional Biosafety Committee (IBC)
and the EHS director.
9.3 Responsibilities
9.3.1 Principal Investigator or Faculty in Charge of Lab
The principal investigator or faculty in charge of the lab is responsible for:
 Identifying the biohazardous waste generated by their activity
 Segregating biohazardous waste into the appropriate waste stream
 Managing biohazardous waste in accordance with this protocol and
 Providing appropriate training to personnel under their supervision.
9.3.2 Biological Safety Officer (BSO)
The biological safety officer is responsible for:
 Providing training upon request for management of biohazardous waste and  Inspecting laboratories to ensure compliance with this protocol.
9.3.3 Environmental Health and Safety (EHS)
EHS is responsible for:
 Picking up those biohazardous wastes requiring offsite treatment from laboratories in a timely
manner
 Final packaging, manifesting and shipping them for disposal and
 Recordkeeping for wastes shipped off-site in compliance with ADH regulations.
9.4 Disinfection
Arkansas Department of Health requires that any material or surface that comes in contact with an
infectious substance must be disinfected prior to reuse. Disinfection is accomplished by appropriate use
of an EPA registered disinfectant used according to the label instructions for the agent being inactivated.
The most familiar disinfectants that are registered with the EPA are bleach (active ingredient sodium
hypochlorite) at a concentration of 10% (1 part household bleach mixed with 9 parts water, hitherto
called 10% bleach), Cavicide, and 70% isopropyl alcohol. However, the disinfectant chosen must be
effective against the agent that is being inactivated. If assistance is needed with this, contact EHS.
9.5 Treatment, Storage and Disposal
Arkansas Department of Health requires that biohazardous (medical) waste be treated by chemical
disinfection, incineration or steam sterilization before disposal. Arkansas State University requires that
all biohazardous waste be treated with 10% bleach (liquids only), sterilized by autoclave or packaged for
offsite contract incineration.
9.5.1 General Storage and Disposal Methods for Different Types of Waste
 Disposable sharps are deposited in a sharps container. All disposable sharps waste are treated
offsite. Re-usable sharps are safely segregated and contained in leak-proof, rigid, punctureresistant containers while awaiting cleaning, decontamination, and sterilization before re-use.
 Liquid biohazardous waste is chemically treated with bleach and disposed via sanitary sewer or
autoclaved and disposed via sanitary sewer or contained in a biohazard bottle which is placed in
a biohazard bin. Biohazard bins are treated offsite by incineration; disposal is by the University’s
Infectious Waste Contractor.
 Solid biohazardous waste is either autoclaved in a clear autoclave bag lacking the biohazard
symbol then disposed of as ordinary trash or placed in a biohazard bin. Biohazard bins are
treated offsite by incineration; disposal is by the University’s Infectious Waste Contractor. Red
or orange bags, or bags marked as biohazard cannot be disposed as ordinary trash, regardless of
whether they were autoclaved.
 Infectious animal body parts or carcasses are contained in biohazard bags, kept in designated
freezers or refrigerators until pickup by EHS. They are placed in a biohazard bin before removal
from the lab. Biohazard bins are treated offsite by incineration; disposal is by the University’s
Infectious Waste Contractor. 9.5.2 Chemical Treatment Standards
 Household bleach is 5.5 - 10 % sodium hypochlorite. The appropriate concentration of sodium
hypochlorite for disinfecting liquid waste, e.g. supernatants from cell culture, is 5000 ppm,
approximately 0.5%. A 1:10 (v/v) dilution of bleach to liquid biological waste is required.
 A minimum contact time of sodium hypochlorite with liquid waste is 20 minutes. After 20
minutes of contact, disinfected liquid waste is poured into the sanitary sewer.
 Bleach should be stored between 50 and 75°F. Undiluted household bleach has a shelf life of six
months to one year from the date of manufacture, after which bleach degrades at a rate of 20%
each year until totally degraded to salt and water (exposure to sunlight or additional heat
increases the degradation rate substantially).
 Any dilution of bleach has a shelf life of 5 days.
9.5.3 Autoclave Standards
All steam sterilizers must:
 Use the biological indicator Bacillus stearothermophillus placed at the center of a load
processed under standard operating conditions to confirm the attainment of adequate
sterilization conditions. Indicator organisms must be used monthly at a generator facility in each
steam sterilizer;
 Record the temperature and time during each complete cycle to ensure the attainment of a
temperature of 121 degrees Centigrade (250 degrees Fahrenheit) for 30 minutes or longer (refer
to Appendix I of the Biosafety Manual for large quantities) at fifteen (15) pounds pressure,
depending on quantity and density of the load, in order to achieve sterilization of the entire
load; (Thermometers shall be checked for calibration at least annually.)
 Have a gauge that indicates the pressure of each cycle.
 Use heat sensitive tape that is lead-free or other device for each container that is processed to
indicate that the steam sterilization temperature has been reached. The waste will not be
considered appropriately treated if the indicator fails.
 Maintain records of the procedures specified in (b) above for a period of not less than three (3)
years.
 Assure that treatment residues are disposed of in accordance with applicable State and Federal
Requirements.
9.5.4 Logging
All wastes that meet the definition of biohazardous waste and are treated chemically or by steam
sterilization must be logged before disposal. The date and amount of waste treated and disposed must
be included. A monthly log must be sent to the EHS at the beginning of each month for the previous
month. A template of the log can be obtained by contacting EHS

Biological Safety Manual

Appendix A Biological Safety Cabinets

Biological Safety Cabinets and other primary containment devices are an essential component of
conducting biological research. As a primary safety barrier, the effectiveness of the BSC is limited by the
techniques employed by the researcher (e.g. good microbiological techniques), an understanding of how
the cabinet functions, and the location of the biological safety cabinet within the facility. As a general
rule, keep biosafety cabinets away from doors, high traffic areas and supply diffusers. The Biosafety
Officer can provide consultation and guidance on the selection, operation and use that meet your
specific research needs.
A Class II, A2 Biosafety Cabinet is recommended and the most common type of BSC in use, as it is
appropriate for most biohazardous work applications. Class II BSC provide personnel protection from
biohazardous materials using HEPA filtered air prior to release into the room, in addition to providing
product protection (to maintain sterility). Information on specific classes and types of Biosafety
Cabinets can be found at https://www.cdc.gov/labs/pdf/CDCBiosafetyMicrobiologicalBiomedicalLaboratories-2009-P.PDF
For most applications, it is not necessary to connect a Class II A2 BSC to the building ventilation
system. Class II A2 cabinets are designed to be “convertible” units and can be connected to the
ventilation system using a thimble connection designed with an air gap. This is recommended only in
certain situations that merit connection to the HVAC system.
Biological Safety Cabinets must be certified annually and whenever moved; they must be
decontaminated (chlorine dioxide gas or hydrogen peroxide vapor) before being moved. BSCs are
certified (and decontaminated) by an outside contractor at the expense of the Principal Investigator. The
Biosafety Officer will provide a list of designated, NSF-certified vendors from which to choose.
Laboratory staff is responsible for coordinating BSC certification service directly with the vendor.
Instructions on the proper use of the Biological Safety Cabinet (BSC)
 Biosafety cabinets are designed to run 24 hours a day, and for frequent work with BSL-2 agents
in the BSC, it is recommended that blowers remain on at all times.
 If it is necessary to turn off the blower, allow sufficient time to purge airborne contaminants
from the work area (Centers for Disease Control and the Public Health Agency of Canada
recommend a minimum of 5 minutes before and 5 minutes after work, taking into account
sufficient time for settling of aerosols).
 Minimize other activities in the room (e.g., rapid movement, open/closing room doors, etc.) to
avoid disrupting the cabinet air barrier.
 Laboratory coats are worn buttoned over street clothing; gloves are worn to provide hand
protection.
 Before beginning work, the investigator must adjust the stool height so that his/her face is
above the front opening.
 Plastic-backed absorbent toweling can be placed on the work surface (but not on the front or rear grille openings). This toweling facilitates routine cleanup and reduces splatter and aerosol
formation during an overt spill.
 Closure of the drain valve under the work surface must be done prior to beginning work so that
all contaminated materials are contained within the cabinet should a large spill occur.
 Place necessary materials in the BSC before beginning work. This serves to minimize the number
of arm-movement disruptions across the air barrier of the cabinet. All materials must be placed
as far back in the cabinet as practical, toward the rear edge of the work surface and away from
the front grille of the cabinet.
 The front grille must not be blocked with research notes, discarded plastic wrappers, pipeting
devices, etc.
 Aspirator suction flasks must contain an appropriate disinfectant, and a High Efficiency
Particulate Air (HEPA) in-line filter. This combination will provide protection to the central
building vacuum system or vacuum pump, as well as to the personnel who service this
equipment. Inactivation of aspirated materials can be accomplished by placing sufficient
chemical decontamination solution such as bleach, into the flask to kill the microorganisms as
they are collected. Once inactivation occurs, liquid materials can be disposed of as noninfectious
waste.
 Horizontal pipette discard trays containing an autoclave bag or an appropriate chemical
disinfectant should be used within the cabinet. Upright pipette collection containers placed on
the floor outside the cabinet or autoclave-safe biohazard collection bags taped to the outside of
the cabinet should not be used. The frequent inward/outward movement needed to place
objects in these containers is disruptive to the integrity of the cabinet air barrier and can
compromise both personnel and product protection.
 All operations should be performed on the work surface at least four (4) inches from the inside
edge of the front grille.
 Active work should flow from the clean to contaminated area across the work surface. Bulky
items such as biohazard bags, discard pipette trays and suction collection flasks must be placed
to one side of the interior of the cabinet.
 Use of glass Pasteur pipettes is discouraged. Glass pipettes should be replaced with safer
alternatives (i.e., plastic) as recommended by the U.S. Department of Health and Human
Services, Centers for Disease Control and Prevention and National Institutes of Health in
Biosafety in Microbiological and Biomedical Laboratories, 5th Edition Fifth Edition and by The
World Health Organization Biosafety Manual. Contact EHS Biosafety for more information on
safer alternatives.
 Open flames (i.e., Bunsen burners) are rarely necessary in the near microbe-free environment
of a biological safety cabinet and are an artifact left over from usage of A1 cabinets (e.g.,
provided only personnel, not product protection) several decades ago. An open flame creates
turbulence that disrupts the pattern of HEPA-filtered air supplied to the work surface. When
deemed absolutely necessary, touch-plate micro-burners equipped with a pilot light to provide a
flame on demand may be used. Internal cabinet air disturbance and heat buildup will be
minimized. The burner must be turned off when work is completed. Micro-incinerators (electric)
are the best alternative for use in the BSC.
 Use of ultraviolet light (UV) in the BSC is strongly discouraged. UV bulbs in the BSC must be
cleaned and monitored regularly, as dust and debris inhibit effectiveness as well as gradual
degradation of the UV bulb over time and should never be used as a primary or sole means of
disinfecting the unit. Therefore, chemical surface disinfection must be the primary means of decontaminating the BSC.
 Clean Up: Upon completion of work, the final surface decontamination of the cabinet must
include a wipe-down of the interior surfaces. Investigators must remove their gloves and gowns
in a manner to prevent contamination of unprotected skin and aerosol generation and wash
their hands as the final step in safe microbiological practice. Investigators must determine the
appropriate method of decontaminating materials that will be removed from the BSC at the
conclusion of the work. 

Biological Safety Manual

Appendix B Shipping of Biohazardous Materials

Biohazardous materials are considered a hazardous material by both the US Department of
Transportation and by the International Air Transport Association (IATA, which oversees air transport of
hazardous materials). Like all hazardous material, special training is required to safely and legally ship
biohazardous materials. Please see the Arkansas State University Hazardous Materials Shipping plan to
determine the type of training needed to ship biohazardous materials.
Biohazardous materials require special shipping containers. There are several vendors that sell the
appropriate containers; consult with EHS before shipping biohazardous materials to make sure that the
shipping containers that will be use meet the regulatory requirements.

Biological Safety Manual

Appendix C Transport of Biohazardous Material

The DOT Hazardous Material Regulations (49 CFR Parts 171-180) regulates the movement of Division 6.2
Infectious Substances when a commercial carrier is used. This is covered in Appendix B: Shipment of
Infectious Substances. Transport refers to movement of Arkansas State material by Arkansas State
personnel (faculty, staff or students) in a vehicle or hand carry between buildings. Substances that meet
the DOT definition of infectious (see Appendix B) and are being transported in a vehicle, must be
packaged per DOT regulations by a person certified to ship infectious substances. Pay particular
attention to the exemptions in the A-State Hazardous Materials Shipping Plan; most substances
requiring transport at Arkansas State are exempt from the DOT definition of infectious.
Substances not meeting the DOT definition of infectious, but requiring BSL-2 (or higher) containment or
covered by Arkansas State’s definition of biohazardous (see Chapter 9 of this Manual) must be packaged
as follows for transport either by vehicle or hand carry: Place material in a primary (specimen) container
that is leak-proof and secured with a tight-fitting cap; place absorbent material (diapers, absorbent
towels, pads) around the primary containers for transport of liquids; place the primary container(s) in a
secondary transport container that is also sealed and labeled with a biohazard symbol.
Arkansas State encourages the use of university-owned vehicles when transporting materials off
campus. Accidents during movement of any of these materials can result in harm to persons and
property. Release and spills of these materials may involve police and HAZMAT responders including
clean-up and cost of recovery. Under NO circumstances may public transportation be used for transport of Hazardous Materials. 

Biological Safety Manual

Appendix D - Use of Human, non-human Primate, and other Mammalian Cells and Tissues

Background: In 1991, the Occupational Safety and Health Administration (OSHA) issued the Bloodborne
Pathogens (BBP) Standard to protect employees who have occupational exposure to human blood or
other potentially infectious materials. While human blood, most body fluids, unfixed human tissues and
organs were clearly included within the scope and application of the standard, the inclusion of human
cell lines was ambiguous.
In 1994, OSHA issued an interpretation of the applicability of the BBP Standard towards human cell lines.
According to the interpretation, human cell lines are considered to be potentially infectious and within
the scope of the BBP Standard unless the specific cell line has been characterized to be free of hepatitis
viruses, HIV, Epstein-Barr virus, papilloma viruses and other recognized bloodborne pathogens. In
alignment with this interpretation, the American Type Culture Collections (ATCC) recommends that all
human cell lines be accorded the same level of biosafety consideration as a line known to carry HIV.
ATCC also states “However, in general, we do not test for animal viruses, therefore not all of our cell
lines have been tested for animal viruses and should be treated accordingly”.
ATCC assigns biosafety level (BSL) designations for the purposes of safe shipment, according to whether
or not at the time of accessioning it is known that the cell lines is harboring any known virus or any
portion of a virus which causes human disease. “While ATTC does provide the biosafety level for each
ATCC culture, we do not provide information on biosafety practices. Each researcher should determine
the appropriate BSL using a risk assessment based on the characteristics of the cell line and how the cell
line will be used.” This includes, but is not limited to, laboratory manipulations employed during its
handling.
Human, primate or mammalian cell lines, even in the absence of overt contamination, may contain
adventitious viruses and/or other opportunistic pathogens or zoonotic agents. Since it is extremely
difficult to screen for every pathogen, all human, primate and mammalian cell lines must be handled
with standard precautions i.e. treated as though they are contaminated with infectious agents and
should utilize BSL2 practices.
In addition to viral and bacterial threats, the European Union – European Medicines Agency document
“Viral Safety Evaluation of Biotechnical Products Derived from Cells lines of Human or Animal Origins”
also indicates the potential for the introduction of bovine spongiform encephalopathy prions (BSE)
contamination into established cell lines via use of contaminated animal-derived products (including
animal serum products) and/or through the use of improper work methods. “However, in contrast to
most of the infectious agents, prions are particularly difficult to inactivate. In fact, no method can
guarantee total inactivation of these agents. So, one should bear these considerations in mind when
using growth media of bovine origin”.
In consideration of the aforementioned regulatory interpretations, consensus guidelines, best practices,
and other factors, the EHS has adopted the following guidance: All cell and organ cultures of human origin, including well established cell lines, human bodily
fluids, non-human primate and mammalian cells and tissues should be handled in accordance
with the OSHA Bloodborne Pathogens Standard and under Biosafety Level 2 (BSL2) containment. 

Biological Safety Manual

Appendix E Guidelines for work with toxins of biological origin

Biological toxins comprise a broad range of poisons, predominantly of natural origin but increasingly
accessible by modern synthetic methods, which may cause death or severe incapacitation at relatively
low exposure levels. Laboratory work with most toxins, in amounts routinely employed in the
biomedical sciences, can be performed safely with minimal risk to the worker and negligible risk to the
surrounding community. Toxins do not replicate, are not infectious, and are difficult to transmit
mechanically or manually from person to person. Many commonly employed toxins have very low
volatility and, especially in the case of protein toxins, are relatively unstable in the environment; these
characteristics further limit the spread of toxins.
Toxins can be handled using established general guidelines for toxic or highly-toxic chemicals with the
incorporation of additional safety and security measures based upon a risk assessment for each specific
laboratory operation. The main laboratory risks are accidental exposure by direct contamination of
mouth, eyes or other mucous membranes; by inadvertent aerosol generation; and by needle-sticks or
other accidents that may compromise the normal barrier of the skin.
A risk assessment should be conducted to develop safe operating procedures before undertaking
laboratory operations with toxins; suggested “pre-operational checklists” for working with toxins are
available. For complex operations, it is recommended that new workers undergo supervised practice
runs in which the exact laboratory procedures to be undertaken are rehearsed without active toxin. If
toxins and infectious agents are used together, then both must be considered when containment
equipment is selected and safety procedures are developed. Likewise, animal safety practices must be
considered for toxin work involving animals.
Detailed information and guidance is contained in BMBL 5th Edition Appendix I:
https://www.cdc.gov/labs/pdf/CDC-BiosafetyMicrobiologicalBiomedicalLaboratories-2009-P.PDF

Biological Safety Manual

Appendix F - NIH Oversight of Research Involving Recombinant DNA

The NIH Guidelines for Research Involving Recombinant DNA Molecules (https://osp.od.nih.gov/wpcontent/uploads/NIH_Guidelines.html) contain procedures for the containment of rDNA research. The
Guidelines apply to all institutions that receive NIH funding for rDNA. All Investigators at the institution
must comply with the Guidelines, even if their individual research is not funded by NIH. Consequences
of noncompliance include suspension, limitation, or termination of NIH funds for rDNA research at the
institution, or a requirement for prior NIH approval of rDNA projects at the institution.
The original guidelines were issued in 1976 due to public concern for safety, environmental impact, and
ethical implications of rDNA research. The purpose of the guidelines is to specify safe handling practices
and containment levels for rDNA molecules, organisms and viruses containing rDNA molecules, and
transgenic animals.

Responsibilities under the Guidelines:
 The Institution must: establish an Institutional Biosafety Committee to ensure compliance with
the NIH Guidelines by investigators and report any significant problems, violations or significant
research-related accidents or illnesses to NIH within 30 days.
 The Institutional Biosafety Committee must: review, approve and oversee rDNA research to
ensure compliance with the Guidelines, determine necessity of health surveillance of
personnel, ensure training for IBC members, staff, PIs, and laboratory staff,
 set biosafety containment levels as required by the Guidelines for some experiments under IIID-4-b
 Incident Reporting to NIH
The following incidents must be reported to NIH OBA within 30 days: any significant problems or
violations of the NIH Guidelines, e.g. failure to adhere to the containment and biosafety practices in the
Guidelines, any significant research-related accidents and illnesses, e.g. spill or accident leading to
personal injury or illness or a breach in containment, e.g. escape or improper disposition of a transgenic
animal.
The following incidents require immediate reporting to NIH OBA: spills or accidents involving rDNA
requiring BSL2 containment resulting in an overt exposure, e.g. needlestick; splash in eyes, nose, mouth;
or accidental aerosolization/inhalation.

Biological Safety Manual

Appendix G Recombinant DNA Experiments Involving Plants

Appendix P NIH Guidelines specifies physical and biological containment conditions and practices
suitable to the greenhouse conduct of experiments involving recombinant DNA-containing plants, plantassociated microorganisms, and small animals. All provisions of the NIH Guidelines apply to plant
research activities with the following modifications:
Appendix P supersedes Appendix G NIH Guidelines (Physical Containment) when the research plants are
of a size, number, or have growth requirements that preclude the use of containment conditions
described in Appendix G. The plants covered in Appendix P include but are not limited to mosses,
liverworts, macroscopic algae, and vascular plants including terrestrial crops, forest, and ornamental
species.
Plant-associated microorganisms include viroids, virusoids, viruses, bacteria, fungi, protozoans, certain
small algae and microorganisms that have a benign or beneficial association with plants, such as certain
Rhizobium species and microorganisms known to cause plant diseases. The appendix applies to
microorganisms that are being modified with the objective of fostering an association with plants.
Plant-associated small animals include those arthropods that: (i) are in obligate association with plants,
(ii) are plant pests, (iii) are plant pollinators, or (iv) transmit plant disease agents, as well as other small
animals such as nematodes for which tests of biological properties necessitate the use of
plants. Microorganisms associated with such small animals (e.g., pathogens or symbionts) are included. For both BSL1-P and BSL2-P, experimental organisms shall be rendered biologically inactive by
appropriate methods before disposal outside of the greenhouse facility. 

Biological Safety Manual

Appendix H - Autoclaves

Autoclaves are safe and highly effective when used properly. They sterilize equipment and supplies and
they kill biologicals and denature proteins. Autoclaves do not remove chemical contamination and
should not be used in conjunction with chemical disinfectants.
Autoclave Cycles
There are three basic autoclave cycles:
1) Gravity Cycle (aka Fast Exhaust): This cycle is used for dry items such as glassware or metal
instruments. This cycle cannot be used for liquids because the rapid pressure release will cause
any liquids to boil.
2) Liquid Cycle (aka Slow Exhaust): This cycle is used to sterilize liquids. The slow pressure release
at the end of the cycle keeps liquids (which have been heated to 121C) from boiling. A table of
autoclave times based on liquid volume is given below.
3) Pre-Vacuum Cycle: This cycle is used for porous materials, animal bedding, etc. Some of the air
in the chamber is evacuated to create a negative pressure space. This allows the steam to
penetrate deeper into the materials placed in the autoclave to help ensure that even the
deepest pockets within these materials become sterile.
When an autoclave is used to kill biologicals prior to disposal, follow the procedures set forth in the
appropriate chapter of the Biosafety Manual.
Safety Rules for Autoclaves
 Hot glassware being removed from the autoclave must be handled with dry, heat-resistant
gloves.
 Use the liquid (slow-exhaust) cycle for liquids and let them stand for 10 minutes before removal
from the autoclave.
 For media bottles (glassware with a sealable cap), the cap must remain loose while the bottle is
in the autoclave. This will prevent it from building pressure and exploding.
 Secondary containment must be used for items being placed in the autoclave. Items should
never be placed directly on the floor of the autoclave.
 Not all plastics can be autoclaved. Polypropylene and polycarbonate may survive the autoclave;
polyethylene, even high-density polyethylene will not. Be sure your item is autoclave safe before
placing in the autoclave. If there is any doubt, use secondary containment.
 To ensure adequate steam penetration, add 1 cup of extra water for dry loads and leave bags
partially open.
 Red biohazard bags must never be used in an autoclave, even if they are autoclave-safe. Clear
autoclave bags must be used.
 Never open an autoclave until the chamber pressure is zero.

 Stand back from the door upon opening to allow excess steam to be released safely.
 And indicator, such as autoclave tape, must be used with each load to ensure the chamber has
reached the appropriate temperature.
Other Autoclave Operating Suggestions
 Placing 1-2 inches of water in the bottom of the secondary container with bottles will help
prevent bottle bottoms from breaking.
 Autoclaving new glassware for 90 minute will partially temper is, making it stronger.
 If there is doubt about whether or not a piece of glassware is autoclave safe, it should be
wrapped in foil. This will capture the pieces of glass if the glassware were to crack or shatter.
Autoclave times based on liquid volume
These autoclave times are only given as guidance. More time may be required for certain organisms or
other biologicals. Allow 10-20 minutes extra for crowded items.
<500 mL 500mL – 1L 1L – 2L 2L-4L 4L
30 minutes 40 minutes 45-55 minutes 55-60 minutes 60 minutes
For any additional questions regarding autoclave use and safety, contact EHS at mdooley@astate.edu.

 

Biological Waste Pickup Request

Biological Waste Pickup Request • CampusOptics

Bloodborne Pathogens and Exposure Control Plan

Bloodborne Pathogens and Exposure Control Plan
Purpose
The purpose of this plan is to ensure that exposure of employees to blood or other potentially infectious
materials is controlled and that those employees are properly trained. This plan is meant to meet the
requirements of the OSHA Bloodborne Pathogens Standard (29CFR1910.1030).
Scope
This plan applies to all employees that may be exposed to blood or other potentially infectious materials
as specified below.
Roles and Responsibilities
Employees
It is the responsibility of the employees covered by this plan to know how to access this plan and to
abide by the requirements herein.
Management/Faculty:
It is the responsibility of management/faculty:
• To understand how this plan applies to their employees and
To ensure that the plan is being followed including:
• Enrollment in medical surveillance;
• Administration of the HBV vaccine and;
• Completion of bloodborne pathogen training. Available in Taleo. Experienced faculty/staff may
administer the bloodborne pathogen training in lieu of EHS training as long as the training
covers all of the covered elements described later in this plan.
Environmental Health and Safety
It is the responsibility of EHS:
• To ensure that this plan stays up to date,
• To provide training that meets the requirements of the bloodborne pathogen standard
• To provide the mechanism by which bloodborne pathogen exposures are reported and
• To assist departments in complying with the requirements of this plan.
Procedures
Exposure determination
The Bloodborne Pathogen Standard requires the employer to make a determination of what positions
have the potential for exposure to blood or other potentially infectious materials (OPIM) as defined by
the standard (including human cell culture). The two classifications are defined below
Exposure Classification I: Job classifications where all employees may reasonably expect to be exposed
to blood or OPIM.
• Law Enforcement personnel
• Physicians and Nurses
• Employees designated to perform first aid
Exposure Classification II: Job classifications where some employees may reasonably expect to be
exposed to blood or OPIM (with the specific tasks given in parentheses).
• Clinical faculty and staff (that work with blood or OPIM)
• Research faculty and staff (that work with blood or OPIM)
• EHS personnel (that collect waste contaminated with blood or OPIM)
• Faculty and teaching assistants (that handle blood or OPIM)
Exposure Classification III: Job classifications that may encounter blood or OPIM but do not do so on a
routine basis.
• Custodians
• Facilities Maintenance staff
• Building managers
• EHS personnel (other than listed above)
• Research faculty and staff (other than listed above)
• Clinical faculty and staff (other than listed above)
• Faculty and teaching assistants (other than listed above)
Work that may result in exposure includes:
• Drawing or processing blood
• Processing human body fluids that are OPIM
• Performing human cell culture
• Picking up contaminated waste
• Performing first aid on an individual that is bleeding
• Cleaning areas or equipment contaminated with blood or OPIM
• Laundering materials contaminated with blood or OPIM
Safety Rules
• Assume all human and animal body fluids are infectious (Universal Precautions)
• Use engineering controls and work practices to eliminate or reduce employee exposure.
• Use personal protective equipment (PPE) when necessary as determined by a hazard
assessment. PPE may include gloves, lab coat or gown, facemask and face shield.
• Keep engineering controls in good working order and under current certification whenever
necessary. Report problems with engineering controls immediately.
• Make handwashing facilities readily available in areas where blood or OPIMs are present.
• Employees must wash hands immediately after PPE removal, i.e., gloves, and if there is any
contact with blood or OPIM.
• Needles should be used one-time only. Contaminated needles and other sharps shall not be
bent, recapped, or removed unless there is no alternative and, in the case of recapping or
removal, a one-handed method or mechanical device must be used.
• Contaminated sharps must be disposed of in containers that are puncture resistant, labeled or
color-coded properly, leak-proof on sides and bottom, and closable on top.
• Eating, drinking, smoking, chewing, applying lip balm or cosmetics, and handling contact lenses
are prohibited in areas where blood or OPIM are present.
• Food and drink shall not be kept in refrigerators, freezers, shelves, cabinets or on countertops or
bench tops where blood or other potentially infectious materials are present.
• Splashing, spraying, spattering and droplet generation (aerosols) will be minimized by using
centrifuge covers and other techniques designed to reduce aerosol formation.
• Mouth pipetting is prohibited.
• Blood specimens or OPIM are transported and stored in leak-proof containers.
• Equipment is decontaminated with disinfectant included in Arkansas State University List of
Approved Disinfectants for Use against Bloodborne Pathogens prior to servicing. This list is
derived from the registered disinfectants that appear on both EPA List E and EPA List F.
• Each work area handling bloodborne pathogens must have a written cleaning schedule including
autoclaving, decontamination procedure using Arkansas State University List of Approved
Disinfectants for Use against Bloodborne Pathogens, and laundry handling. The supervisor is
responsible for this schedule. An autoclave must also be conveniently available.
• Each supervisor is responsible for reviewing the effectiveness of the individual controls, and
making corrections to conform to the Bloodborne Pathogens Standard.
Personal Protective Equipment
Required personal protective equipment shall be used in accordance with a performed hazard
assessment. The assessment may be done by the person in charge of the area (faculty or manager) or
the EHS director. The EHS director must approve the level of PPE used.
• Disposable PPE should be used whenever possible.
• Reusable PPE shall be laundered on the premises whenever contamination is suspected. No PPE
may be taken home to be laundered.
• PPE shall be supplied, replaced and cleaned at no cost to the employee.
Training
• All employees in exposure classification I, II or III must complete BBP training as early as
practicable. Additional in-person training may be performed by a faculty or staff member
knowledgeable on the subject or by the EHS director.
• All the employees must take an annual refresher either in person or online.
The training that is given must include each of the following elements:
• Explanation of epidemiology, symptoms, and transmission modes of bloodborne diseases.
• How to recognize bloodborne hazards.
• How to prevent or reduce exposure.
• How to minimize aerosol production.
• Handling needles properly.
• Information and instruction on Personal Protective Equipment location, selection, removal,
decontamination, and disposal.
• Instruction on hand washing procedures.
• Information on biological waste handling and disposal.
• Information on the Hepatitis B vaccine.
In-person training, provides opportunity for interactive questions and answers with a technicallyqualified person.
• Explanation of the contents of Standard 1910.1030.
• Explanation of and access to the Exposure Control Plan.
• Information on the appropriate actions to take and persons to contact in an emergency
involving blood or other potentially infectious materials.
• Explanation of color coding and labeling per 1910.1030(g).
• Handling of biological waste.
Training records should be kept by the individual giving the training and supplied upon request.
Hepatitis B Vaccine
Employees in exposure classification I or II or those newly assigned to either of these classifications will
be offered the HBV vaccination within 10 working days of initial assignment.
• The employee may decline the vaccination by signing the Hepatitis B Vaccine Status Form.
• The cost(s) of the vaccinations will be borne by the employee’s department.
• The employees that receive the vaccination may not work with blood or OPIM until at least 10
days after receiving the first of the three HBV injections.
• Employees that were born in 1995 or after may have had the HBV vaccine series as a child. This
must be confirmed by the employee and noted in the record.
Exposure Procedure
IMMEDIATELY FOLLOWING EXPOSURE
Exposure to blood or other potentially infectious materials that could result in infection with a
bloodborne pathogen can happen by one of two routes:
• Puncture with a contaminated needle or other sharp object or
• Blood or OPIM entering the open wound of the exposed individual.
If the exposure is the result of a medical emergency, the employee should be taken to the nearest
emergency medical center. The steps following may take place after the employee has been taken for
emergency medical care.
• If an exposure occurs, the exposed employee must immediately report the exposure to his or
her supervisor.
• The supervisor should immediately call the Injury Nurse Hotline (855-339-1893) to report the
exposure.
• The employee should receive medical attention as soon as possible. CDC recommendations
state that prophylaxis is most effective when initiated within two hours of the incident;
therefore, it is imperative that the employee go to one of the below listed medical facilities
providing services for the Workers’ Compensation program as soon as possible.
• The supervisor and employee must complete all of the steps required by the Workman’s
Compensation procedure after this point. For more information on this procedure view here.
Post-Exposure Follow-up
The results of the medical evaluation are to be strictly confidential between the healthcare professional
and employee. The exposed employee’s supervisor will obtain a written notice from the healthcare
professional and provide a copy to the employee following completion of the medical evaluation. The
notice will not contain any findings or diagnoses. The notice to the supervisor should contain the
following:
• A statement that the employee has been notified of the evaluation results
• A statement that the employee has been notified of any medical conditions that may arise from
the exposure which may require further treatment
• All records must be kept in accordance with the Recordkeeping section of this Plan

Laboratory Information Questionnaire

Laboratory Information Questionnaire

 

Lab Inspection Cheat Sheet

Lab inspection cheat sheet

CDC Training for Transporting Biological Materials

CDC Training for Transporting Biological Materials

Biosafety in Microbiological and Biomedical Laboratories (BMBL) 6th Edition

Biosafety in Microbiological and Biomedical Laboratories (BMBL) 6th Edition

Lab Inspection SOP

1. PURPOSE
The purpose of this procedure is to outline the process used for conducting laboratory inspections at
Arkansas State University.
2. SCOPE
This procedure applies to all laboratories of Arkansas State University.

3. DEFINITIONS
3.1 Deficiency: A problem found during an inspection that must be corrected.

3.2 PI: Principal Investigator
3.3 Laboratories: All labs belonging to Arkansas State University campus including those off
campus that contain biological, chemical, physical, or radiological hazards.
3.4 PPE: Personal Protective Equipment
3.5 DSL: Department Safety Liaison
3.6 Inspection team: The person or persons inspecting a lab
3.7 IDLH: Immediately Dangerous to Life or Health

4. RESPONSIBILITIES
4.1 Arkansas State University Department Heads
4.1.1 Communicate the importance of following safety policies and procedures identified in the
Arkansas State University Laboratory Safety Manual, Biological Safety Manual, Radiation
Safety Manual and Hazardous Waste Management Plan.
4.1.2 Encourage and support laboratories to conduct self-inspections using the self-inspection
checklist and explanation key.
4.1.3 Encourage Principal Investigators to correct deficiencies noted by the inspection team.
4.2 Arkansas State University Principal Investigators and Lab Managers
4.2.1 Understand and follow safety policies and procedures identified in Arkansas State
University Laboratory Safety Manual, Biological Safety Manual, Radiation Safety Manual and
Hazardous Waste Management Plan.
4.2.2 Be aware of the self-inspection checklist and explanation key and use them to prepare for
lab inspections.
4.2.3 Ensure all deficiencies found during lab inspections are corrected by the appropriate
deadline.
4.3 Arkansas State University EHS

4.3.1 Maintain and update the inspections webpage, self-inspection checklist and
explanation key and other resources to assist researchers meet their safety and
compliance responsibilities.
4.3.2 Schedule and perform laboratory inspections according to the goals and objectives
and this SOP.
4.3.3 Follow-up on noted deficiencies according to this SOP.

5. LABORATORY INSPECTION SCHEDULING
5.1 The following steps are involved for scheduling laboratory inspections.
1) Send out email memo to PIs two weeks prior to the planned start date for inspections.
Included in the email memo should be a link to the inspection template and a lab
characterization sheet. The PI or lab representative may have to fill out and return the lab
characterization sheet which includes a lab roster.
2) Send out a subsequent email memo one week prior to the initiation of inspections. This
memo should include a list of the labs in a facility with the name of the person responsible for
the lab attached. Request the PI or lab representative to ensure the information in the list is
still correct.
3) Set schedule based on time requests by Principal Investigators or other lab representative.
4) Add inspection time to calendar with an invite for the appropriate DSL.

5) Complete the inspections per the schedule.
6) Notify PI or lab representative if critical deficiencies are found that will result in imminent
closure of the lab (see DEFICIENCIES section below).
7) Give inspection results to the lab representative at the end of the inspection. A more detailed
report may follow at a later time if further information is needed or is requested.
5.2 While the scheduling period for a facility should be over the course of 4-6 weeks, exceptions
should be made for labs whose PI wishes to present for inspections but whose schedule does
not allow it during the given time period.
6. LABORATORY REPRESENTATION DURING INSPECTION
6.1 The PI or his/her designee should be present during the lab inspection. The lab representative
should be knowledgeable of the daily operations of the lab and must be employed by
Arkansas State University.
6.2 If the PI refuses to have lab representation for the inspection, carry out the inspection with
the appropriate DSL present.
6.3 If the PI refuses to have lab representation for the inspection and the appropriate DSL is not
available, the case shall be referred to the Director of EHS.

6.4 If possible, the appropriate DSL should be present during some of the inspections.
7. INSPECTION
7.1 Before the lab visit, a roster of the lab workers should be provided by the PI or other lab
representative. Based on the lab characterization, the inspection team should check to be
sure that all lab workers have completed all appropriate training.
7.2 Prior to the inspection, the Principal Investigator in charge of the lab should have the lab
users examine the inspection template to see items that will be checked. Correcting
deficiencies prior to the inspection is allowed and encouraged.
7.3 A representative of the lab should meet the inspection team outside of the lab to ensure that
the inspection team is apprised of the hazards of the lab and have the appropriate PPE.
7.4 During the inspection, the lab representative should stay with the inspection team to answer
any question the team may have.
7.5 The inspection should take anywhere from 20 minutes to an hour. Large labs may take longer
than an hour. (Note: On the first round of inspections, the process may take longer due to the
new procedure and the length of time since previous inspections).
7.6 Only items addressed on the inspection form may be counted as deficiencies. If a critical item
is found that is not on the checklist, it may be counted as a deficiency at the discretion of the
Director of EHS.
7.7 At the end of the inspection or by the end of the inspection day a copy of the inspection
results are given to the lab representative. A more detailed report may be provided at a later
time if necessary.
7.8 It is the goal of EHS to visit each lab once per year. After going through the first round it may
be determined that higher risk labs need more frequent visits while lower risk labs may only
require biannual (every other year) inspections.
8. DEFICIENCIES
8.1 Deficiencies are classified as non-compliant and critical
8.2 Critical Deficiencies
8.2.1 Deficiencies found that are IDLH can result in immediate closure of the lab. If such a
deficiency is found:

8.2.1.1 Contact the PI responsible for the lab for immediate resolution.
8.2.1.2 If the deficiency cannot be corrected immediately, the PI refuses to correct this
deficiency or the PI or another lab representative cannot be reached:
8.2.1.2.1 Contact the Director of EHS
8.2.1.2.2 Once the director gives approval for closure of the lab, post signage stating
that the lab is unsafe for entry and contact information.
8.2.1.2.3 Contact the appropriate DSL to lock the lab
8.2.2 If a deficiency is critical but is not IDLH, a time frame must be established for correction of
the deficiency.
8.3 Re-inspection on the basis of deficiencies
8.3.1 A lab will be re-inspected if:
8.3.1.1 A critical deficiency is found
8.3.1.2 The number of other deficiencies is high enough to cause the total inspection
percentage to be below 80%
8.3.2 Re-inspection of labs will not be announced, but at least one week will be given to correct
non IDLH deficiencies
8.4 Correction of Deficiencies
8.4.1 Whether or not re-inspection occurs, it is the responsibility of the PI to ensure that ALL
deficiencies are corrected.
8.4.2 Correction of deficiencies, can, in some cases, be evidenced to the inspection team by
photograph.
8.4.3 Continued failure to correct deficiencies to an acceptable level will result in an escalation
process described in the next section
9. ESCALATION PROCESS

9.1 Unless the deficiencies found are sufficiently critical to the life and health of the lab workers
or the regulatory status of the laboratory, laboratories will be given a minimum of two weeks
to correct deficiencies.
9.2 If upon follow-up inspection critical deficiencies remain unresolved or the laboratory
inspection correct percentage remains below 80% an email message will be sent reminding
the PI in charge of the lab and the appropriate DSL as to the status of the lab. An additional
seven days will be given to bring the lab into compliance.
9.3 If after these seven days the lab is still non-compliant (does not meet the criteria of 9.2),
another email communication will be sent to the PI, the appropriate DSL and the Chair of the
appropriate department. An additional seven days will be given to bring the laboratory into
compliance.
9.4 At this point the PI has had a minimum of 28 days to bring the lab into compliance. If the lab
is still not in compliance, then a third email communication will be sent to the PI, the
appropriate DSL, the Chair or the appropriate department and the Dean for the appropriate
college.
9.5 If the lab still fails to comply after two weeks of the dean being contacted, the Associate Vice
Chancellor of Research or the Vice Chancellor for Academic Affairs (depending on whether
the lab is a research lab or a teaching lab) will be contacted to inform them of the imminent
closure of the lab due to non-compliance. Human Resources may also be contacted.
9.6 Failure to bring a lab into compliance after the 28 days will also result in the refusal of the EHS
to sign any safety documentation regarding grants or permits until such time as the lab is in
compliance.
9.7 Extensions to any of these periods may be granted at the discretion of EHS. A request for an
extension should be requested by an email to the inspection team.
9.8 The escalation process will NOT be used for lab inspection findings that are out of the control
of the PI. For items outside the control of the PI a separate escalation process will be used.
10. REFERENCE DOCUMENTS FOR SELF-INSPECTION
10.1 Included in the email to the PI regarding the scheduling of the inspection will be links to the
following documents:
10.1.1 A blank copy of the inspection form

10.1.2 An explanation of the criteria for each inspection item to achieve the highest level of
compliance
10.1.3 The Laboratory Safety Manual
10.1.4 The Chemical Hygiene Plan
10.1.5 The Biological Safety Manual
10.1.6 The Hazardous Waste Management Plan
10.2 Requirements to meet the minimum compliance level will be linked to the appropriate
regulation or standard as a demonstration of why the item is being checked in the inspection.
11. BENEFITS FOR HIGH COMPLIANCE RATINGS
11.1 Laboratories that have no critical deficiencies, score higher than 95% minimum compliance
and meet the highest compliance level (currently called excellent) on 50% or more of the
inspection items will have the advantage of the following benefits:
11.1.1 A streamlined process for signing off on safety documentation for permits or grants
wherever EHS has that responsibility
11.1.2 Priority on inspection scheduling
11.1.3 The opportunity to self-inspect in lieu of EHS inspections (high risk labs do not qualify)
11.1.4 Other benefits TBD