The University of British Columbia

In the next few years a significant proportion of the research faculty will be leaving UBC. In order to ease the transition between the previous and the new tenants of the research facilities, HSE has drafted a proposed protocol to facilitate the changeover.

Further heightening the need to ensure a smooth transition is the advent of WHMIS, provincial and federal environmental regulations, Atomic Energy Control Board Regulations and MRC Guidelines for Biohazards. These regulations have made it mandatory that principal investigators decommission laboratories to ensure that the legal and ethical expectations associated with such work are met.

The purpose of the following protocol is to provide a framework for Department heads to develop a site specific exit protocol for research faculty under their supervision. Properly applied, an exit protocol ensures that:

• Departmental policies and procedures are followed.
  
• Unsafe conditions are eliminated.
  
• A proper clean-up is performed.
  
• Lab equipment is properly disposed/recycled.
  
• Hazardous materials are properly disposed/recycled.
  
• Work surfaces are free of contamination.
  
• Regulatory requirements are met.

Notification

When a faculty member informs their Department head of their intentions to leave UBC, (suggested minimum three months notice) the Department head shall provide a copy of the Departmental exit protocol. It is suggested for purposes of due diligence that the date of this information transfer be documented. It is then the responsibility of the department head to monitor that the faculty member follows all the steps in the protocol to completion, including all requirements for documentation.

Checklist

A checklist will provide a simple method for the Department head to confirm the protocol has been completed. The faculty member shall submit a completed exit protocol checklist to the department head prior to departure. The department head shall keep a copy and a copy shall also be provided to the faculty member. A generic checklist is available from HSE and Department heads may wish to modify and enhance any aspect of the list.

EXIT PROTOCOL FOR UBC PRINCIPAL INVESTIGATORS

[HSE: June, 2006]

Procedure

When the primary researcher or supervisor of a laboratory leaves or decommissions a laboratory, the following procedures shall be followed.

• General
  
  
  1. A current inventory of all hazardous materials must be completed.
     
  2. All unknowns must be identified and appropriately labeled.
     
  3. All chemicals should be removed from the laboratory, by transferring to another primary researcher/laboratory supervisor, or by disposal through the Environmental Services Facility.
     
  4. The Departmental Safety Committee should inspect the laboratory to ensure removal of all material and approve the removal by signing the inventory form.
     
  5. A copy of the approved inventory list should be sent to the Departmental Head or Director. It is the responsibility of the Department Head or Director to ensure that adequate procedures are followed for the decommissioning of laboratories.
  
  
• Transfer of chemicals to another primary researcher/laboratory supervisor
  
  All materials transferred must be labeled according to WHMIS requirements and the receiving party must obtain appropriate Material Safety Data Sheets. For further information contact the University Occupational Hygiene Officer, 604- 822-2643.
  Some of the materials may be forwarded to the University Chemical Exchange Program for future use. Contact the ESF at 822-6306 for further information.
  
  
• Disposal of chemicals
  
  The identity of all materials must be established before disposal. If there are unidentified materials, contact Health, Safety and Environment to arrange for materials to be classified for waste disposal purposes; there will be a cost associated with this process (~$100.00 - ~$150.00/hour).
  
  A chemical disposal inventory form must be completed for all chemicals ready for disposal, and forwarded to the Department of Health, Safety & Environment. Following approval by ESF staff, the materials must be packaged according to the instructions provided and then arrangements are to be made with ESF at 822-6306, for pick-up of the material.
  
  Return compressed gas cylinders to suppliers.
  
  
• Radioisotope Licence De-activation and Laboratory Decommissioning
  
  Required from the Licensee:
  
  1. Memo to Radiation Safety Office (RSO) stating intent to discontinue the isotope licence.
     
  2. Complete a set of wipe tests for every laboratory licensed for isotope use.
     
  3. Record of proper disposal of all isotopes on hand (this can include a gift of remaining isotope to another researcher that is licensed for that nuclide).
     
  4. Completion of a yearly isotope inventory (from RSO).
     
  5. If the researcher is leaving the University, or does not intend to re-activate the licence at some future date, all isotope purchase, usage, disposal and contamination control records must be forwarded to the Radiation Safety Office.
  
  Following the completion of the above steps, the Radiation Safety Officer will remove all signs. Thereafter, a letter will be issued to the researcher stating that the licence is no longer active. Decommissioning of laboratory space is not complete until verification by the Radiation Safety Office.
  
  
• Biohazard Laboratory Decommissioning
  
  
  1. Notify Biosafety Office (604-822-7596) that biohazard protocols are to be concluded.
     
  2. Record transfer of Biohazardous materials to the inventory of another researcher.
     
  3. Terminate all Biohazards not transferred to the inventory of another researcher.
     
  4. Decontaminate all working surfaces.
     
  5. Conclude liquid nitrogen delivery contract.