1

Laboratory Inspection Checklist

Principal Investigator:

Inspection Number:

Lab Representative(s):

Date of Inspection:

Permit/Certificate Number(s): Inspector:

Room Number(s)/ Lab Designation(s):

Inspection History:

Deficiencies discovered last inspection (Inspection date:________________)

Status of Deficiency Correction

2

Inspection Section A: General Laboratory Safety

Ratings: Compliant = √ Non-Compliant = X Not Applicable = NA Unknown = ?

Inspection Items Requirement Ratings Comments

Security 1. Is access to the laboratory restricted to authorized personnel/

authorized visitors only?

GNSCR 12, CBS 4.5.2, LSM 3.2

a. Are trainees supervised until authorized? CBS 4.3.8

2. Is the lab separate from public areas by a lockable door?

Describe Locking mechanism (key, card, other)?

CBS 3.1.1, CBS 3.3.1,

GD-52

3. Are RAM/BIO/CHEM hazards left unattended? GNSCR 17

4. Are RAM/BIO/CHEM hazards inaccessible to unauthorized individuals?

How (i.e. locked refrigerator, locked storage box, etc.)?

NSRD LC-2575, CBS

4.6.20

5. If barrier windows are openable, is there effective pest control/security in place?

GD-52, CBS 3.2.1

6. Are doors kept closed? CBS 4.5.1

Signage

7. Is appropriate hazard warning signage posted at all entrances to the lab?

RPR 21, NSRDR 23, CBS 3.3.2, LSM 2.1

a. Do signs contain the required information? i. Correct symbols? Wording? (e.g. “RAYONNEMENT-

DANGER-RADIATION” for RAM labs)?

NSRDR 23, CBS 3.3.2

ii. Correct BIO containment level/RAM laboratory classification?

NSRD LC-2570, CBS

3.3.2

iii. Are unique hazards, if present, identified on signage? CBS 3.3.3

iv. Is emergency contact information present and correct? NSRDR 23, CBS 3.3.2, LSM 2.1

v. Are requirements for entry, if any, present? NSRDR 23, CBS 3.3.2, CBS 4.5.8

3

8. Is there frivolous posting/display of RAM/BIO signs? RPR 23, RSOP 08B

9. Are internal authorizations (e.g. RAM permit) and authorized worker lists posted within the lab and up to date?

NSRDR 36, NSRD LC-

2215, RSOP 08B

Emergency/Life Safety

10. Are emergency eyewash/shower facilities available as per ANSI Z358.1?

NL OHS Reg 42, 63, ANSI Z358.1 GD-

52, CBS 3.6.6

a. Is appropriate signage available? Are weekly checks conducted and documented?

ANSI Z358.1

11. Are spill kits appropriate for the hazard(s) available in the lab? NL OHS Act 5.2, LSM 10.1.1,

RSOP 11, BSOP 03

a. Are spill kits adequately stocked?

b. Are spill kits routinely checked/signed-off for contents?

c. Do workers know how to use spill kits?

12. Are fire extinguishers available? (provide certification date) NFC 6.2

13. Is a fully stocked first aid kit, with no expired items available? Is signage available?

NL FA Reg 11

14. Is a two way communication system available? CBS 3.7.18, LSM 2.5.4

Personal Protective Equipment (PPE)/Lab Safety

15. Is dedicated PPE available and worn while working with CHEM/RAM/BIO?

NL OHS Act 5.2, 7, LSM 2.4, GNSCR

17, CBS 4.4.1

a. Lab coat, appropriate shoes, gloves, eye protection (if necessary)?

CBS 4.4.4 LSM 2.4

b. Are PPE donned and doffed in a manner that minimizes contamination (according to SOP)?

CBS 4.4.1, CBS 4.5.14,

LSM 2.4

c. Is space available for PPE storage (near the point(s) of entry)?

GD-52, CBS 3.3.9

4

d. Is PPE worn outside of the lab? CBS 4.4.1, CBS 4.5.15,

LSM 2.4

e. Is PPE decontaminated prior to laundering if an exposure occurs?

CBS 4.8.5, LSM 2.4

f. Are personal belongs/clothing stored away from PPE and hazard (eg handling, storage) areas?

CBS 4.5.10, CBS 4.5.11

16. Is there any evidence of food/drink within the laboratory? GD-52, LSM 2.3

17. Is long hair restrained? CBS 4.6.2, LSM 2.3

Laboratory Safety Equipment

18. Are hazards adequately contained while in use (time, distance, shielding for RAM; containment equipment for BIO; fume hood for CHEM)?

19. Are chemical fume hoods required? (provide recent certification date)

NL OHS Regs 42

a. Are fume hoods cluttered or used for storage? LSM 5.3

b. Are sash height and flow failure indicators present? NL OHS Regs 45

c. Are volatile chemicals and volatile RAM used solely in the fume hood?

GNSCR 12, NL OHS Regs 42, LSM 3.2

20. Are essential safety equipment on emergency power?

Physical Laboratory 21. Are surfaces/furniture non-absorbent and easily

decontaminated/cleaned?

GD-52, CBS 3.4.1

a. Are surfaces in disrepair? Absorbent material exposed? GD-52, CBS 3.4.1, NL

OHS Regs 67

22. Are floors slip resistant and in good condition? CBS 3.4.5, NL OHS Regs

67

23. Is a hand-washing sink (with amenities) available for hand-washing?

GD-52, CBS 3.6.4

24. Are paperwork areas separated from laboratory work/storage areas?

GD-52, CBS 3.1.2, CBS

4.6.8

5

25. Is the laboratory clean and free from unnecessary materials (i.e. tidy) or materials that may be difficult to decontaminate?

NL OHS Regs 458, CBS

4.6.35

Operational 26. Have workers completed general safety training (are records

available)?

BIO RAM WHMIS/Lab Safety

NL WHMIS Regs 5, LSM

4.1.3.1, GNSCR 12, CBS 4.3.1

27. Have workers received lab/job-specific training (are records available)?

LSM 4.1.3

28. Are workers working with RAM/BIO/CHEM safely/securely and according to policies/procedures? (observe workers)

GNSCR 17, NSRD LC-

2917

29. Have there been any incidents (spills, lost/stolen materials, device damage, unauthorized release, breach of security, sabotage, personal exposure (LAI), containment system failures, etc.) since the last inspection? (describe)

GNSCR 12, GNSCR 17, RSOP 03,

CBS 4.10.11, HPTA 12-14

a. If so, were incidents reported? (e.g. >100 EQ RAM spill requires reporting, HPTA reporting)

b. Are records kept for required period (e.g. CBS - 10 years)? CBS 4.10.12

30. Is hand washing required after removing gloves and before exiting laboratory? After working within fume hood/BSC?

CBS 4.8.3, LSM 3.2

31. Are open wounds covered with waterproof dressings? CBS 4.6.6

32. Are sharps disposed in CSA approved containers? CSA Z316.6-95

33. Are laboratory safety/emergency procedures (i.e. RSOP/RSM, BSOP, etc.) available to workers at worksite?

NL OHS Act 5.2, NSRDR

17, CBS 4.1.15

a. Is there a documented Laboratory Safety Plan? LSM 1.3.2

Notes:

6

Inspection Section B: Radiation Safety

Inspection Items Requirement Ratings Comments 34. Is a properly functioning contamination meter available? NSRD LC-

2572

35. Is an up to date wipe map available for all authorized location?

RSOP 11

36. Is contamination monitoring completed within prescribed time frame (i.e. 7 days of RAM use)?

RSOP 11

37. Are areas above "dirty" or "action" contamination limits cleaned and re-wiped and, if necessary, reported to RSO?

RSOP 11, NSRD LC-

2642

a. Do workers know contamination limits? “dirty” = 0.5 Bq/cm2, MUN = 30 Bq/cm2 (for Class C isotopes); CNSC = 300 Bq/cm2 (for Class C isotopes)

38. Is inventory accurate and up to date (HSMS)? NSRDR 36

a. Are there unauthorized items present? NSRDR 36

b. Are use/disposal records available and up to date? NSRDR 36

39. Are dose rates outside of storage areas, rooms or enclosures < 2.5 uSv/hr? Use meter to check.

NSRD LC-2575

40. Is disposal of RAM waste approved by RSO prior to disposal? (verify with records)

NSRD LC-2160,

GNSCR 12

41. Are containers or devices with > 1 EQ labeled appropriately (trefoil, isotope name, activity, date of measurement and form)?

RPR 20, RSOP 08B

42. Is thyroid monitoring/screening (> 2 MBq) or tritium bioassays (>400 MBq) required?

NSRD LC-2046, NSRD

LC-2600, RSOP 01B

43. Are radioisotopes used on humans? NSRD LC-2690

44. Are radiation dosimeters worn (if required)? RPR 5

45. Are field devices properly labelled (name & 24-hour number)? NSRDR 22

46. Is a copy of the current NSRD license posted in the building/taken into the field?

Provide Location of posting

GNSCR 14

7

47. Are required signs/posters posted within the lab? RSOP 08B, NSRD LC-

2570

a. CNSC/MUN containment safety poster (EQ, SS/Ins, Basic, Intermediate)?

NSRD LC-2570

b. CNSC spill response poster? RSOP 08B

c. CNSC package receipt poster? RSOP 08B

48. Is TDG-7 required? (Type A package receipt)? (review certificate to expiry date)

PTNSR 25

49. Are packages received according to CNSC/MUN guidelines?

Ask procedure used

PTNSR 40, RSOP 06

a. Checked for damage? Reported if damaged? PTNSR 40

b. Wipe tested and dose surveyed? (review records) Reported if above limits?

RSOP 06

c. Receipt documentation retained 2 years? (review records)

PTNSR 31

Notes:

8

Inspection Section C: Biological Safety

Inspection Items Requirement Ratings Comments 50. Is an up to date inventory available (including items stored

outside of the CZ)?

CBS 4.10.2

a. If stored outside CZ, is it stored in labelled, leak-proof, impact resistant container with restricted access?

CBS 4.6.20

51. Are BSC (if required) annually certified and located away from high traffic areas?

CBS 3.7.1, CBS 3.7.6, CBS 4.6.15

a. Are BSC used for the required procedures (according to LRA)?

CBS 4.6.24

b. Are on-demand flames limited and sustained flames prohibited within BSC?

CBS 4.6.30

52. Are vacuum systems (if present) equipped with a filter and/or disinfectant trap?

CBS 3.7.17

53. Are the disinfectants used effective against the materials in use?

CBS 4.8.2

a. Are working solutions labeled with the preparation date? (recommendation)

54. Are biohazards appropriately decontaminated prior to disposal? (describe)

CBS 4.8.5, CBS 4.8.7, CBS 4.8.

55. Is non-sterilized waste transported outside of the CZ? CBS 3.7.11

a. If yes, is BSOP followed?

56. Are surfaces decontaminated before and after work? CBS 3.7.11

57. Is PPE/contaminated clothing decontaminated prior to laundering?

CBS 4.8.5

58. Are autoclave monitoring/recording devices functioning and provide operational parameters?

CBS 3.7.14

59. Are autoclave logs, including BI results, up to date? CBS 3.7.15, CBS 4.8.11, CBS 4.10.9

60. Have workers completed lab-specific training? CBS 4.3.10

a. Does lab-specific training cover hazards associated with work, symptoms of illness and preventative measures?

CBS 4.3.2

b. Does lab-specific training cover CZ design/operation and use/operation of lab equipment? (sample records)

CBS 4.3.3, CBS 4.3.4

9

61. Is emergency response refresher training given annually and documented?

CBS 4.3.10

62. Is all training documented? (check training logs) CBS 4.10.1

63. Have any of the following occurred (ask): a. increase the virulence or pathogenicity of a human

pathogen

HPTR 5

b. increase the communicability of a human pathogen HPTR 5

c. increase the resistance of a human pathogen to preventive or therapeutic treatments

HPTR 5

d. increase the toxicity of a toxin HPTR 5

i. If yes to any, was the BSO informed? HPTR 5

Notes:

10

Inspection Section D: Chemical Safety

Inspection Items Requirement Ratings Comments 64. Is mercury present in the lab?

65. Are chemicals stored in proper cabinets? NL OHS Regs Section 59.2 NFC, Section

5.5 Subsection 5.5.5.1 or

Subsection 5.5.5.2 NL

a. Are cabinets/trays in good condition? Leaking?

b. Are appropriate spill trays used for corrosive materials? NL OHS Reg 31

LSM Sec 5.3

c. Are known/suspected human reproductive toxins (teratogens), sensitizers or acutely toxic chemicals, if present, stored/handled appropriately?

NL OHS Regs Section 42

66. Are SDS available and up to date? NL WHMIS Regs 13, 15;

67. Are chemical inventories available and up to date? LSM Section 5.3

68. Are gas cylinders stored properly (chained at 2/3 ht, caps on when not in use)?

NL OHS Regs 450

69. Are chemicals (used, expired or unstable) disposed of correctly? (describe)

LSM Section 5.3

a. Are waste containers available?

i. Flammable waste volume (L) (>1<20) (>20 <40) (>40)

ii. Corrosive waste volume (L) (>1<20) (>20 <40) (>40)

iii. Other waste volume (L) (>1<20) (>20 <40) (>40)

70. Are chemicals segregated according to chemical compatibility?

NL OHS Regs Section 42.5,

58; LSM Section 5.3

71. Are chemicals labelled with WHMIS compliant labels? NL WHMIS 7.(3), 9.(1)

11

GNSCR – General Nuclear Safety and Control Regulations; PTNSR – Packaging and Transport of Nuclear Substances Regulations; RPR – Radiation Protection Regulations; NSRDR – Nuclear Substances and Radiation Devices Regulations; NSRD LC – Nuclear Substances and Radiation Devices License Condition; RSOP – Memorial’s Radiation Safety Operating Procedures; GD-52 – Design guide for nuclear substances laboratories and nuclear medicine rooms; CBS – Canadian Biosafety Standards; HPTR – Human Pathogens and Toxins Regulations; BSOP – Biosafety Standard Operating Procedures; CSA – Canadian Standards Association; NFC – National Fire Code; LSM – Memorial’s Laboratory Safety Manual; NL OHS ACT/Regs – NL Occupational Health and Safety Act/Regulations; NL WHMIS Regs – NL Workplace Hazardous Materials Information System Regulations; NL FA Regs – NL First Aid Regulations

Notes:

12

Item # Action Items Responsible Person(s)

Due Date

1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

11.

12.

13.

14.

15.

16.

17.

18.

19.

20.

PI (print): _______________________________ PI (signature): __________________________________ Date: ____________________

Inspector (print): __________________________ Inspector (signature): __________________________ Date: ____________________