A. INTRODUCTION

The Chemical Hygiene Plan is part of the campus Health and Safety program (Policy and Procedure 290-15, Safety Management Program) to minimize exposures to chemical hazards in the laboratory. The UC Davis Chemical Hygiene Plan has been developed in response to California Occupational Safety and Health Administration (Cal/OSHA) requirements; California Code of Regulations (CCR) Title 8, Section 5191, Occupational Exposure to Hazardous Chemicals in Laboratories. This standard, also known as the Laboratory Safety Standard, was developed to relieve laboratories from the burdens of complying with regulations directed at industrial activities and to protect the health of laboratory personnel at places like UC Davis through training and communication of information.

UC Davis Environmental Health and Safety prepared this Chemical Hygiene Plan. It is intended to serve as a basic guide to develop laboratory-specific Chemical Hygiene Plans. Laboratory- specific plans must address policies, hazards, work practices, procedures, and precautions that are unique to the laboratory. Other laboratory-specific information should include emergency procedures, location of reference materials, a chemical inventory, description of control measures such as fume hoods and personal protective equipment, and prior approvals. To help laboratories develop their plans, EH&S has provided several forms to assist with developing laboratory-specific information. Appendix B contains directions and forms for completing the Chemical Hygiene Plan.

In a university setting, all work is pursued in a community environment. Each person's safety is affected by the action of others in the laboratory. It is in everyone's best interest to be familiar with the work of others, and to insist that fellow workers in the laboratory follow safe work practices.

Report conditions that pose a threat to the health and safety of the occupants of a laboratory immediately to the laboratory supervisor. All injuries should be immediately treated at Employee Health Services or Cowell Student Health Center and reported to the supervisor for processing through the Worker's Compensation Program.

B. SCOPE AND APPLICATION OF THE LABORATORY STANDARD

1. The laboratory standard applies where hazardous chemicals are used or stored on a laboratory scale. "Laboratory scale," means that the containers used for reactions, transfers, and other procedures are designed to be easily and safely manipulated by one person. At a minimum, this definition includes employees who use chemicals in teaching, research, and clinical laboratories at the UC Davis Campus and the Medical Center. Also, it is UC Davis policy that students in laboratories, while not legally covered by this standard, are afforded the same level of protection as UC Davis employees.

C. CHEMICAL HYGIENE PLAN

This Chemical Hygiene Plan includes the following components and indicates specific measures that UC Davis departments, laboratories, and personnel must take to ensure laboratory employee protection. Laboratory-specific plans must be reviewed and updated annually by responsible laboratory personnel.

1. Standard Operating Procedures (Administrative Controls)
   Standard Operating Procedures (e.g., work practices, procedures, and policies) relevant to laboratory safety and health must be prepared in writing and followed when work involves the use of hazardous chemicals. Standard Operating Procedures may specify general safety precautions (e.g., safety equipment, work practices, general housekeeping practices), accident responses, waste disposal, and spill clean-up procedures. Additional laboratory-specific Standard Operating Procedures should be developed on a case-by-case basis for hazardous procedures unique to the laboratory. For guidance on writing Standard Operating Procedures, see Appendix A.
2. Engineering Controls
   Engineering controls include chemical fume hoods, biosafety cabinets, glove boxes, and room ventilation.Engineering controls can be very effective and are the preferred method for reducing exposures. At UC Davis, there are a variety of engineering controls in use, the most common is the ventilation system. EH&S recommends the following parameters for ventilation controls (for more information, see Chapter IV).
1. General laboratory room ventilation should meet a minimum of 6 air changes per hour, with good air distribution and be slightly negative (a minimum of 100 cubic feet per minute per door) relative to hallways, public and other non-laboratory areas.
2. Work with toxic or flammable chemicals should always be done in a fume hood. Fume hoods should provide an average of 100-120 linear feet per minute (lfpm) of face velocity at the hood face opening with no area less than 70 lfpm.
3. Other engineering controls such as local exhausts (snorkels or elephant trunks) and glove boxes can be used for special ventilation purposes. Contact EH&S for additional information if special ventilation or other engineering controls are needed.
3. Maintenance of Engineering Controls
   Evaluation and maintenance of engineering controls at UC Davis is a joint effort between EH&S and Facilities Services.
1. Chemical fume hoods are inspected annually by Facilities Services for proper operation and airflow. Sash level stickers are placed on vertical rising sash chemical fume hoods when they are surveyed. These stickers indicate the same level at which the chemical fume hood sash should be operated (maximum operating height no greater than 18"). Contact the Facilities Services Service Request Center at 752-1655 if your fume hood has not been inspected or is not working properly.
2. Each chemical fume hood should have a label indicating the date it was last inspected and the measured face velocity.
3. All chemical fume hoods must have a flow indicator to display that the fume hood is operational.
4. If any engineering control (e.g., fume hood, glove box, local exhaust) or alarm does not seem to be working properly, contact Facilities Services Service Request Center at 752-1655.
4. Personal Protective Equipment
   If engineering controls and administrative controls (e.g., substitution of a less hazardous chemical, rotation of personnel, altered work schedules) are not feasible for controlling employee exposure, personal protective equipment must be used. Personal protective equipment such as respiratory protection, eye protection, and gloves must be matched to the chemical and physical hazards of the operation. Personal protective equipment must be properly maintained to obtain maximum protection. See Chapters V and X for more information on personal protective equipment.
5. Employee Information and Training
1. Departments must provide laboratory personnel with information and training to ensure awareness of the physical and health hazards of the chemicals present in the work area. Information and training may relate to an entire class of hazardous chemicals. Information and training should be provided at the time of an employee's initial assignment to a work area where hazardous chemicals are present and prior to assignments involving new potential exposures.
2. Information should include the following:
1. The contents and availability of UC Davis' Chemical Carcinogen List (Chapter VII).
2. The location and availability of the departmental Injury and Illness Prevention Plan.
3. The location and availability of laboratory-specific Chemical Hygiene Plans.
4. The Permissible Exposure Levels for Cal/OSHA-regulated substances and Threshold Limit Values (TLV’s) for other hazardous chemicals where there is no applicable Cal/OSHA regulation (Chapter VI). Material Safety Data Sheets (MSDSs) are a useful source of this information.
5. The location and availability of known reference material on the hazards, safe handling, storage, and disposal of hazardous chemicals in the laboratory. This includes, but is not limited to, Material Safety Data Sheets (MSDSs). See the Bibliography for a list of reference materials.
3. Training should cover the following:
1. Signs and symptoms associated with exposures to hazardous chemicals used in the laboratory. Material Safety Data Sheets (MSDSs) are often a source of this information.
2. Methods that may be used to detect the presence or release of a hazardous chemical. This could include industrial hygiene monitoring, the use of continuous monitoring devices, visual appearance, or odors of chemicals.
4. EH&S offers regular chemical and laboratory safety training and will assist departments with training by request. In addition, laboratory personnel must be trained for laboratory-specific hazards not covered in general training. Training and education should be a regular, continuing activity as opposed to simply an annual presentation. The department, supervisor, or the Principal Investigator must retain training documentation. A sample training documentation form is provided in Appendix B.

 D. IMPLEMENTATION OF THE CHEMICAL HYGIENE PLAN

1. In order to meet the requirements of the Laboratory Safety Standard, a Chemical Hygiene Plan must be customized for each UC Davis laboratory. The Principal Investigator or laboratory supervisor is responsible for the development and implementation of the customized plan.
2. The Chemical Hygiene Plan must be readily available to all employees and students in the laboratory. The term "readily available" means accessible to all laboratory staff at any time, day or night.
3. EH&S has provided the basic elements of a general Chemical Hygiene Plan. Each laboratory should provide additional information to make this plan specific to the laboratory. This may be accomplished by filling out the forms found in Appendix B. There is not a prescribed way to fill out these forms. If the required information is already available from other sources, attach copies of originals to the forms. This information will be unique to the laboratory.
4. The following forms in Appendix B should be completed:
1. Site-Specific Responsibility for Chemical Hygiene and Safety.
2. UC Davis Chemical Inventory: including physical form, maximum amount stored, annual usage rate, etc. Including the Chemical Inventory System (CIS) printout is appropriate.
3. Specific Information on Chemical Receiving, Storing, or Dispensing (if applicable).
4. Material Safety Data Sheets (MSDSs) and Other References Available in the Laboratory.
5. Emergency Response Instructions.
6. Site-Specific Hazardous Materials Control Systems (Engineering Controls).
7. Personal Protective Equipment Available in the Laboratory and when it is required to be used.
8. When Prior Approvals are Required for using specific substances and equipment.
9. Laboratory-Specific Standard Operating Procedures. There is a recommended form in Appendix A.
10. UC Davis Regulated Carcinogen Use Registration Form, if applicable (see Chapter VII).
11. Laboratory Training Checklist (use one form per employee).
12. Laboratory Safety Survey Form (laboratories should be surveyed at least annually by laboratory personnel). See the attached Laboratory Safety Survey Guidelines for guidance.

Also include a copy of the Worker’s Compensation UC Davis Employer’s Report of Occupational Injury or Illness (WCER) form that must be filled out in the event of personnel exposure or injury.

E. RESPONSIBILITY FOR IMPLEMENTATION OF THE CHP

Responsibility for the implementation of the Chemical Hygiene Plan (CHP) and the Injury and Illness Prevention Program (IIPP) lies at all levels including: (see P&PM 290-15)

1. The Department Chairperson or Director: Is responsible for establishing and maintaining programs that will provide a safe and healthy work environment.EH&S will provide technical guidance to the department in the development and implementation of the department's Injury/Illness Prevention Program and Chemical Hygiene Plans.

2. The Chemical Safety Administrative Advisory Committee: Sets policy, provides consultation, technical assistance, and recommendations relating to chemical safety to the Vice Chancellor of Administration.

3. Principal Investigators, Laboratory Managers, and Supervisors are responsible for implementing the safety program and maintaining compliance as it relates to operations under their control. In addition, they must ensure that:

1. the Chemical Hygiene Plan includes laboratory-specific information, names of responsible laboratory staff, and is reviewed and updated at least annually.

2. employees receive general chemical hygiene training offered by EH&S, the department, or the equivalent, as well as training on laboratory-specific hazards.

3. training is documented.

4. acceptable written safety policies and procedures are developed for laboratory personnel to follow.

5. appropriate personal protective equipment is purchased and used.

6. employee compliance is evaluated.

7. Laboratory personnel perform periodic (at least annual) laboratory safety inspections.

4. The Office of Environmental Health and Safety:

1. Promotes programs for compliance with safety and health regulations, and for the protection of the health and safety of students, faculty, staff, and visitors.
2. Assists departments in providing general training sessions to laboratory personnel.
3. Provides guidance to departments and laboratory personnel in developing IIPP and laboratory-specific Chemical Hygiene Plans.
4. Provides guidance to laboratory personnel in developing laboratory-specific Standard Operating Procedures.
5. Periodically visits the work environment to help identify hazards and recommend corrections.
6. Upon request, monitors the work environment for airborne contaminants. Makes a recommendation for control of exposures.
7. Provides consultation on health hazards related to chemical exposures.
8. Maintains records of any measurements taken to monitor employee exposures.
9. Serves as campus liaison with Cal/OSHA and other regulatory agencies.
5. Laboratory Workers (including students and employees) are responsible for:
1. Following the established work procedures and safety guidelines in their area, as well as those identified in the Chemical Hygiene Plan and the UC Davis Chemical and Laboratory Safety Manual.
2. Inquiring about and using personal protective equipment to protect themselves from hazards.
3. Notifying the PI, Laboratory Supervisor, or EH&S of any unsafe or potentially unsafe condition.

F. PERMISSIBLE EXPOSURE LIMITS

Laboratory exposures to hazardous chemicals must not exceed the Cal/OSHA Permissible Exposure Limits(Chapter VI).

G. EXPOSURE DETERMINATION

EH&S will provide consultation on chemical use, evaluate worker exposures, and suggest exposure control methods. If an employee could be exposed routinely above the Permissible Exposure Limit, monitoring will be performed by EH&S. If initial monitoring reveals that an employee is exposed to levels greater than the action level (one-half the Permissible Exposure Limit), a monitoring program will be established. Engineering controls, administrative controls, or personal protective equipment may be recommended to reduce employee exposures. Monitoring may be stopped when exposures are reduced below the action level.Employees will be notified of monitoring results in writing within 15 working days after EH&S receives the monitoring results.

H. PRIOR APPROVAL

1. UC Davis has established several advisory committees to review laboratory protocols and/or approve the use of hazardous materials. These committees are:
1. Animal Use and Care Administrative Advisory Committee (AUCAAC)
2. Chemical Safety Administrative Advisory Committee (CSAAC)
3. Human Subjects Review Committee (HSRC)
4. Biological Safety Administrative Advisory Committee (BSAAC)
5. Radiation Use Committee (RUC)
2. In addition, EH&S should be contacted prior to beginning or continuing laboratory operations under the following conditions:
1. When it is likely that the Cal/OSHA Permissible Exposure Limits (Chapter VI) could be exceeded.
2. When the laboratory staff show symptoms, suspect that they or others have been exposed to a chemical, or otherwise suspect a failure of any safeguards.
3. When working with explosives, extremely reactive chemicals, extremely toxic chemicals, or large quantities of material that could potentially be released to the environment (air, water, or land).

I. HAZARD IDENTIFICATION

1. Departments, Principal Investigators, and laboratory workers should ensure that labels on containers of hazardous chemicals are not removed or damaged. Mixtures or materials that have been transferred to containers other than the original container must be properly labeled with contents, hazard warnings, date prepared, and name of person who re-containered the materials. Laboratories must also maintain a chemical inventory and provide access to Material Safety Data Sheets (MSDSs) for all laboratory chemicals.
2. For hazardous chemicals produced in the laboratory:
1. If the chemical composition is known and the chemical is produced exclusively for the laboratory of origin, the Principal Investigator will provide and document training (e.g., toxicological properties, safe handling procedures, potential hazards, etc.) as described in this plan.
2. If the chemical produced is a by-product with an unknown composition, the Principal Investigator will assume that the substance is hazardous and will implement this plan.
3. If the chemical substance produced is sold to a user outside the laboratory, the Principal Investigator will comply with the Hazard Communication Standard, including preparation of MSDSs and labeling. See section J below and contact EH&S for more information on the Hazard Communication Standard.
3. Laboratory-prepared solutions of hazardous chemicals must be labeled with the identity of the chemical and an appropriate hazard warning. The identification used must permit cross-reference to the laboratory's MSDS collection.

J. USE OF PARTICULARLY HAZARDOUS CHEMICALS

Procedures described in this section should be followed when performing laboratory work with particularly hazardous chemicals. These include chemical carcinogens (Chapter VII), reproductive toxins (Chapter XI), acutely toxic substances, and highly reactive materials. The following provisions must be considered and included when working with particularly hazardous chemicals:

1. Within chemical laboratories, designated areas should be posted and boundaries clearly marked.

   1. A designated area could be a restricted access chemical fume hood, glove box, or portion of a laboratory designated for use of a particularly hazardous substances. All those with access to the area must be aware of the substances being used and the necessary precautions to be taken.
   2. Only persons with training and demonstrated knowledge and ability to work with particularly hazardous chemicals should work with those chemicals in the designated area.
2. Use containment devices, such as fume hoods or glove boxes, when using particularly hazardous volatile chemicals; when procedures involve manipulations that could result in the generation of an aerosol or airborne dust; and with any manipulation, handling, or reaction that may result in the uncontrolled release (explosion) of the substance.
3. Follow procedures for proper disposal of contaminated chemical wastes (Chapter VIII).
4. Decontamination procedures vary depending on laboratory circumstances. Contact EH&S for specific decontamination procedures.

K. MEDICAL CONSULTATION / EXAMS

1. All employees who work with hazardous substances will be included in the medical surveillance program:
   
   1. Whenever an employee develops signs or symptoms of exposure to a hazardous chemical to which the employee may have been exposed in the laboratory.
   2. Where exposure monitoring reveals an exposure level routinely above the action level for a Cal/OSHA-regulated substance for which there are exposure monitoring and medical surveillance requirements. Medical surveillance will be established for the affected employee as prescribed by the relevant standard.
   3. Whenever a spill, leak, explosion, or other occurrence results in the likelihood of a serious overexposure to a hazardous chemical, the affected employee must be given an opportunity for medical consultation.
   4. Where other regulations mandate medical consultations such as for the use of chemical carcinogens, for the use of respiratory protection, and for animal handlers.
2. All medical exams and consultations will be performed by or under the direct supervision of the campus occupational physician and will be provided without cost to the employee.
3. The following information must be provided to the physician:
   
   1. the identity of the hazardous chemical(s) to which the employee may have been exposed;
   2. a description of the conditions under which the exposure occurred including quantitative exposure data, if available; and
   3. a description of any signs or symptoms of exposure the employee is experiencing.
4. UC Davis will obtain a written opinion from the examining physician which includes the following:
   
   1. any recommendation for further follow-up;
   2. the results of the medical exam and any associated tests;
   3. any medical condition revealed in the course of the examination that may place the employee at increased risk as a result of exposure to a hazardous chemical found in the workplace; and
   4. a statement that the employee has been informed by the physician of the results of consultation or medical examination and any other medical condition that may require further examination or treatment.

The written opinion will not reveal specific findings of diagnosis unrelated to occupational exposure.

L. RECORD KEEPING

1. UC Davis Employee Health Services maintains records for each employee included in this medical surveillance program. These records include any measurements taken to monitor employee exposures and any medical consultation and examinations including tests or written opinions.
2. Employee exposure monitoring records are permanently maintained by EH&S. Exposure records include environmental monitoring and related collection and analytical methodologies, calculations, and other background data relevant to interpretation of the results; biological monitoring results, and specific Material Safety Data Sheets (MSDSs).
3. The UC Davis Employee Health Center will maintain medical records for each employee in strict confidence. Medical records of employees who have worked for less than one year for the University need not be retained beyond the term of employment if they are provided to the employee upon termination of employment