University of California San Francisco
Clinical & Industrial Hygiene
Hazardous Materials Management
Radiation Safety Officer
Chemical Safety Officer
Controlled Substances Officer
Campus Fire Marshal
Public Safety Officer
Complete listing of EH&S staff, see the EH&S website- Contact Us
TABLE OF CONTENTS:
Office of Environment Health & Safety
50 Medical Center Way
San Francisco, CA 94143-0942
Campus Mail: Box 0942
Phone: 476-1300, Fax: 476-0581
The Office of Environment Health and Safety (EH&S) assists the campus community with the evaluation, planning, development, and execution of health, safety and environment programs.
EH&S has established safety program for biological materials, radiation, fire and life, occupational health and research, environment permitting and monitoring, safety management, hazardous materials management, and removal of regulated waste. The department acts as University liaison with federal, state, and local regulatory agencies in interpreting the requirements of these agencies, evaluating potential hazards, and correcting violations of safety standards.
EH&S provides a variety of services to campus departments. These include but are not limited to indoor air monitoring, ergonomic advice, instrument calibration, bioassays, wipe tests for contamination, removal of medical, chemical, radioactive and controlled substance waste, and laboratory inspections.
EH&S also provides consultation and training, and makes recommendations for environment management and applied research. EH&S assists the University by evaluating the impact of its activities on the environment.
The EH&S Director oversees the inventory and application process for all state and local permits regulating hazardous materials storage, air toxics emissions, sewer discharge, underground storage tanks, waste disposal and other environment issues.
EH&S assists both the UC Office of the President Long Range Planning and the UCSF Campus Planning as needed, with the development of Environment Assessments and Environment Impact Reports. EH&S also coordinates with the Office of the President’s Facilities Management-Risk Management and the Office of the General Counsel on legal and regulatory issues.
EH&S acts as liaison between UCSF and the neighborhood community and assists the UCSF Public Affairs Office in addressing community environment issues.
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Hazardous Materials EH&S Response Team
Program EH&S has established the Hazardous Materials EH&S Response Program to provide 24-hour emergency support to UCSF campus, Medical Center, and satellite locations.
The on-call Hazardous Material EH&S Responder is an EH&S Specialist who is available seven days a week, 24 hours a day to provide technical assistance to the UCSF university community. The on-call responder is activated through 9-911 calls made to UCSF Police Dispatch. The responder is available 24 hours a day, has a fully equipped hazardous materials spill response van, and will respond within 10 minutes after receiving calls for assistance.
The Hazardous Materials EH&S Response Program complements existing campus policy which specifies that researchers are responsible for the clean-up of minor spills. The EH&S Response Team (ERT) generally responds to larger spills.
The ERT responds to “stabilize the situation” to protect human health and the environment. The ERT does not fully mitigate a hazardous materials spill or release. After stabilizing a hazardous material spill emergency event, the final mitigation of the situation is the responsibility of the Department, or Principal Investigator.
Reporting Procedures After identifying a spill or release of a hazardous material the following reporting procedure should be followed:
1. Attend to injured or contaminated persons and remove them from exposure. Avoid unnecessary movement in order to prevent the spread of contamination.
2. Alert persons in the immediate area to evacuate.
3. Call UCPD at 9-911 or 476-6911 and provide the following information:
- call back phone number
- location of spill
- identity of spilled material
- quantity spilled
- any other pertinent information.
The UCPD will then contact the Hazardous Materials EH&S Responder.
4. Close doors and restrict access to affected area.
5. Have a person knowledgeable with the incident available to assist emergency personnel.
PROGRAM SERVICES CHART
Central Administration and Finance Director of Finance and Administration ----Suzanne Murphy
- Contract Administration
- Financial Management
Campus Program Manager ------------------------ Kelly Nguyen
- Animal Care Facility Monitoring
- Biosafety Bloodborne Pathogens Training
- Biosafety Certifications and Decertification
- Biosafety Consultations and Inspections
- Biosafety User Authorization Support
- Carcinogen Usage and Registration
- Chemical Safety Consultation and Inspections
- Chemical Safety Manual\Chemical Hygiene Plan
- Ergonomic Evaluations
- Fire and Physical Safety Consultation and Inspections
- Hazard Communication Program
- Laboratory Accident Investigations
- Radiation Consultation and Inspections
- Radiation Dosimetry Program
- Radiation Safety Certifications and Decertification
- Radiation Training
- Radiation User Authorization Support
- Research Controlled Substances Usage and Registration
- Safe Shipping of Biohazards Training
- Sealed Source Monitoring
- Training (Health and Safety)
- Workplace Safety Evaluations and Inspections
Hazardous Materials Management Program Manager------------------------------------ Tim Orozco
- Air Toxic Emission
- Chemical Waste Collection
- Chemical Waste Analysis and Consultation
- CUPA Compliance
- Deluge Shower and Eyewash Station Monitoring
- Due Diligence
- Environment Permit Applications
- Fume Hood Evaluation
- Hazardous Materials Inventories (Business Plan)
- Material Safety Data Sheet Resource Library
- Radiation Detection Instrument Calibration
- Research Controlled Substances Receiving
- Research Controlled Substances Collection & Disposal
- Medical Waste Removal and Contract Oversight
- Radioactive Materials Receiving & Delivery
- Radioactive Material Transport
- Radioactive Waste Collection
- Thyroid & Urine Bioassays
- Waste Minimization Program
- Wipe Test Services
- Underground Storage Tanks Compliance and Inspection
Clinical & Industrial Hygiene Program Manager --------------------------------------------------
- Agency Liaison
- Asbestos Material Sampling
- Asbestos Abatement Oversight and Coordination
- Asbestos Training and Notification
- Central Administrative
- Community Air Quality and Noise Surveys
- Emergency Response Program
- Facility Plans Review
- Fire & Physical Safety Consultations and Inspections
- Food Inspections
- Hospital Safety
- Indoor Air Quality Evaluations
- Occupational and Environment Exposure Monitoring
- Patient Care Area Monitoring
- PCBs, Lead
- Respiratory Protection Program
- Services Program
- Ventilation System Evaluation
Central Administrative Services Program
- Director of Finance & Administration: 476-5782
- Business Services: 476-0539
- Recharges: 476-0539
The Environment Health and Safety Central Administrative Services Program is responsible for accounting and analysis, departmental purchasing, programmatic administrative services, contract administration, recharges and financial management, information services, personnel and payroll.
The program will assist users of EH&S services in solving recharge, contract and other related financial operational problems.
SERVICES & RESPONSIBILITIES:
Accounting and Financial Management. Act as departmental liaison to the University accounting and budget offices.
Forms. A variety of EH&S forms, both admin and technical are available on EH&S web site.
Contract Administration. Monitor departmental vendor contract payments on behalf of the University to ensure contract compliance.
Recharges and Financial Management. Coordinates all recharge activities between Campus EH&S service users and the Department. This includes Radioactive Waste Collection Services, Wipe Test Services and Instrument Calibration.
(Refer to currently posted Recharge Rates on the EH&S website)
- Program Manager: 476-3328
- Safety Specialists: 476-1300
The Campus Program supports the research and administrative departments of UCSF for all environment, health, and safety issues. The program is built around the concept of a EH&S Specialist (Department Safety Advisor or DSA).
Each department on campus is assigned an EH&S specialist as the single point of contact for all EH&S issues and activities. The DSA, works closely with the Department Head, Chief Administrative Officer, Principal Investigators (PI), and their laboratory managers to identify and mitigate workplace hazards, and to ensure compliance with applicable environment and health and safety regulations.
The DSA can either provide or obtain resources within EH&S to address all health and safety issues.
The Campus Program supports the Radiation, the Biosafety, the Chemical committees and their associated officers. The Campus Group interfaces with the Environment Health and Safety (EH&S) User Committee to ensure that the EH&S needs of the Campus community are met.
Program policies are in accordance with the current standards of good practice, the provisions of the University Licenses, the laws of the city of San Francisco and the State of California and the U.S. Government covering environment, health or safety practices.
It is the responsibility of EH&S to maintain awareness of applicable policies and regulations, and to provide information on implementation of each to the UCSF community. The EH&S web site contains links to many government agencies, regulatory agency requirements and professional organizations.
SERVICES & RESPONSIBILITIES:
Laboratory Animal Resource Center (LARC) Monitoring
EH&S has a DSA assigned to the Animal Care Facility. In addition, the Biosafety Officer conducts regular inspections of LARC.
Biosafety and Bloodborne Pathogens Training
The Campus Program offers initial and yearly refresher training for all campus personnel. Training is tailored to the needs of the work assignments.
Biosafety Certification and Decertification
EH&S verifies availability of biosafety equipment (biosafety cabinets, autoclaves), facilities suitability and laboratory practices and procedures as appropriate to meet the risk-level of the studies performed at that site.
Biosafety Consultation and Inspections
The DSAs perform regular inspections of laboratories for the purpose of identifying and mitigating biohazards and for assuring the laboratory’s compliance with biosafety policies, guidelines, and regulations. The DSAs are also available for consultation in biosafety.
Biological User Authorizations Support
DSAs perform evaluations of laboratory practices, safety equipment and facilities as a part of the Biological Use Authorization (BUA) approval and renewal process. DSAs are also available to assist the investigator with preparation of the BUA application, and to support the Biosafety Committee’s review process.
NOTE: For more information regarding the Biological Safety Program and requirements for using biohazardous materials at UCSF, please see the
UCSF Biosafety Manual, distributed by EH&S and available online at the EH&S website.
Carcinogen Usage and Registration
EH&S is responsible for maintaining appropriate registrations for campus users of certain carcinogens, reviewing the work practices of the carcinogen users, coordinating an exposure monitoring and/or medical surveillance program as needed.
Chemical Safety Consultation and Inspections
The DSAs perform regular inspections of laboratories for the purpose of identifying and mitigating chemical hazards and for assuring the laboratory’s compliance with safety policies, guidelines, and regulations. The DSAs are also available for consultation in the chemicals and hazardous materials area.
Chemical Safety Manual/Chemical Hygiene Plan
EH&S prepares and implements the UCSF Chemical Hygiene Plan (CHP). The CHP is embodied in the UCSF Chemical Safety Manual. Chemical Safety Policy is established by the UCSF Chemical Safety Committee, in accord with regulatory requirements. The entire chemical safety manual is available on the EH&S website.
Disaster and Emergency Preparedness and Planning
The Campus Program assists in preparation of department Emergency Action Plans, provides training in emergency preparedness, inspects worksites for earthquake preparedness, and is available for consultation on this topic.
DSAs are available to evaluate ergonomic properties of individual work stations and work practices. Training in proper lifting techniques is also available.
Fire and Physical Safety Consultation and Inspections
The DSAs perform regular inspections of all campus facilities for the purpose of identifying and mitigating fire and physical hazards and for assuring compliance with safety policies, guidelines, and regulations. The DSAs are also available for consultations on this topic. DSAs work closely with the Campus Fire Marshal to ensure fire safety requirements are met.
Hazard Communication Program
The DSAs support the implementation of the UCSF Hazard Communication Program. They provide training in chemical labeling, storage and in use of Material Safety Data Sheets. They are available for consultation in identifying and mitigating workplace hazards.
Injury and Illness Prevention Program (IIPP)
DSAs support implementation of the UCSF IIPP by helping develop individual department safety committees, and by performing other services described herein.
Laboratory Accident Investigations
EH&S investigates laboratory accidents, attempting to determine causes and complicating factors, and recommending ways to prevent future occurrence. Lessons learned are communicated to campus personnel during OEH&S training sessions, and via the EH&S newsletter.
Radiation Dosimetry Program
A Campus Program representative is responsible for distribution, pick-up and all recordkeeping associated with personnel monitoring and area monitoring devices.
Radiation Safety Certifications and Decertification
EH&S verifies availability of appropriate safety equipment (shielding, meters, fume hoods), facilities suitability, and laboratory practices and procedures as appropriate to meet the risk-level of the studies performed at the site.
Radiation Safety Consultations and Inspections
DSAs perform regular inspections of laboratories for the purpose of identifying and mitigating radiation hazards and for assuring the laboratory’s compliance with radiation safety policies, guidelines, and regulations. The DSAs are available for consultation in the radiation safety area.
Radiation Safety Training
All personnel who work with radioisotopes must be trained to understand the associated hazards and to use proper techniques in working with isotopes. This training must occur before the individual can begin use of radioisotopes. The Campus Group provides online training. Radioisotope users must be retrained biennially.
Radiation Use Authorization (RUA) Support
DSAs perform evaluations of laboratory practices, safety equipment, and facilities as a part of the RUA approval process. DSAs are also available to assist the investigator with preparation of the RUA application, and to support the Radiation Safety Committee’s review process.
Research Controlled Substances Usage and Registration
EH&S is responsible for recognizing controlled substance hazards, developing safe procedures through peer review, newsletters, and communications with campus users, and maintaining registrations.
Sealed Source Monitoring
All radioactive sealed sources must be inventoried quarterly and leak-tested semiannually. DSAs are available to support the inventory and to perform the leak testing.
The Campus Group can provide training for all environment, health, and safety topics, as necessary for the safety and well-being of all campus employees. Each DSA coordinates the needs and training schedules for assigned departments. For a list of training courses offered by EH&S go to the UC Learning Center.
Safe Shipping of Biohazards
The Biosafety Officer provides initial and biennially refresher training on the safe shipping of biohazardous materials. These sessions include local, state, federal, and international regulations regarding paperwork and shipping containers. A certificate is provided to all those who successfully complete their session. These certificates are legally required if you need to ship by common carrier, and are being required by these carriers before they will accept this category of “dangerous goods”.
Workplace Safety Evaluations and Inspections
The DSAs perform regular inspections of all campus work areas for the purpose of identifying and mitigating hazards not covered by other processes (physical hazards, electrical hazards), and for assuring compliance with employee health and safety regulations. DSAs are also available for consultation on any safety issue.
Hazardous Materials Management Program
- Program Manager: 476-1480
- Environment Compliance: 476-5506
- Chemical Waste Operations: Chemical Waste Minimization 476-1480
- Hazardous Materials Services: Due Diligence Medical Waste Oversight Controlled Substances Disposal 476-1480
- Radioactive Waste Operations: Wipe Test Services 476-1771/476-1772
- Radiation Technician Operations: Receiving and Delivery of Radioactive Material 476-1771/476-1772
- Radiation Survey Meter Calibration Thyroid Bioassays Controlled Substances Receiving 476-1771/476-1772
- Mt. Zion Radiation Safety Lab: Phone: 502-1129 Fax: 502-1199
- Mission Bay Genentech Hall Receiving Phone: 514-4107 Chem Waste Phone: 514-4108
- Bio Waste Phone: 514-4107 Fax: 514-4160 (N121) Fax: 514-4297(N101)
The Hazardous Materials Management Program (HMM) oversee services related to hazardous chemical waste collection; radiation survey instrument calibration, radioisotope receiving and delivery, radioactive waste collection, thyroid and urine bioassays, wipe test services, controlled substances receiving, collection and disposal, research medical waste collection, and environment permits.
The HMM program arrange for the pickup and disposal of hazardous waste from all UCSF locations. This Group is responsible for maintaining the necessary permits, licenses, and registrations to operate and manage EH&S hazardous waste facilities and for overseeing the consolidation, packaging, and removal of the waste from UCSF sites.
The HMM program oversee chemical, radioactive and medical waste removal contracts. Audits of vendors are conducted as needed.
SERVICES & RESPONSIBILITIES:
Chemical Waste Collection
Collect hazardous (chemical) waste from all UCSF locations. Arranges with vendors for final disposal, maintains shipping manifests, waste removal records, and transporter permits.
Deluge Shower and Eyewash Station Monitoring
HMM Program representative functionally checks all deluge showers and eyewash stations on a monthly basis. On a yearly basis, deluge shower flow rates are verified. EH&S is available for consultation on selection and appropriate placement of deluge showers and eyewash stations at all UCSF locations.
HMM assist UCSF property managers in performing their due diligence responsibilities prior to leasing rental space by performing a technical review of the property and preparing a written report on findings. The review focuses on environment issues associated with the prior uses of hazardous materials or hazardous wastes (e.g. chemical, radioactive, and biological materials or wastes).
HMM represent UCSF on behalf of EH&S with environment regulatory agencies and secures needed environment permits, licenses, and/or registrations. This includes required air, sewer discharge, and underground/above storage tanks permits. Compliance with permit conditions and necessary agency reporting is also provided.
Fume Hood Evaluation
HMM Program representative is responsible for placement, testing, and function of all fume hoods on the UCSF campuses. Fume hoods are tested and certified yearly.
Hazardous Materials Inventories (Business Plan)
The City of San Francisco mandates a complete inventory of hazardous chemicals and other hazardous materials at UCSF biannually. DSAs are available to assist their departments in performing the inventory and providing the appropriate documentation.
Safety Data Sheet (SDS) Resource Library
The HMM Program is responsible for the availability of SDSs for all hazardous materials used at UCSF. EH&S assures hard copy and/or electronic access to SDSs for all chemicals in the chemical inventory. HMM Specialist can arrange for distribution of SDSs to users. The EH&S web site contains links to several SDS databases.
Medical Waste Removal
Collect medical waste from UCSF campus research laboratories. Arranges with vendors for final disposal, maintains shipping records and required permits. Oversee UCSF Medical Waste Management Program.
EH&S coordinate and maintain responsibility for all permits required by regulatory agencies, including the City of San Francisco, the State of California, and the Federal Government.
Radioactive Waste Removal
Collect, package, and arrange for final disposal of radioactive waste from all UCSF locations. Arranges with vendors for final disposal, maintains all required regulatory records including shipping manifests.
Recharge Rates for Radioactive Waste Collection Services
See Administrative Information Services Program page 8.
Radiation Survey Instrument Calibration
HMM pick up, calibrate, and arrange for return of radiation survey meters. The UCSF Radioactive Material License requires annual inspection and calibration of these instruments.
Radioisotope Receiving and Delivery
Radioactive materials are delivered to EH&S authorized Radioisotope Receiving Area (such as Long-235G, Mission Bay Genentech Hall N121 and Mt. Zion N 130). Shipments are surveyed for contamination. Radiation use authorization is verified and the material is delivered to the laboratory.
Research Controlled Substances Receiving
HMM receive controlled substances at Parnassus and Mission Bay. Upon receipt of the substances from either the Medical Center Pharmacy or from commercial distributors, the documentation of each package is verified for accuracy and completeness. Only registered controlled substance users are allowed to pick-up approved shipments at the receiving laboratory.
Research Controlled Substances Collection and Disposal
Disposal of expired and unwanted controlled substances are not permitted. These substances must be surrendered and disposed of properly through the OEH&S Controlled Substances program. HMM staff arranges for proper disposal with approved outside vendors and maintain required shipping and disposal records.
Thyroid and Urine Bioassays
Users of volatile radioactive iodine are required to undergo a thyroid scan on a frequency determined by the UCSF Radioactive Materials License. The scan is performed at the Parnassus campus Radioisotope Receiving Area (Long 235G) and at Mission Bay Genentech Hall (N121) following procedures prescribed by the Radiation Safety Officer.
Wipe Test Services
UCSF license requires laboratories using radioactive material to perform wipe testing on a regular basis. HMM provides this service on a recharge basis.
Note: For more information about the UCSF Radiation Safety Program, refer to the UCSF Radiation Safety Manual, available at the EH&S web site.
Clinical & Industrial Hygiene Program
- Program Manager: 476-1300
- X-Ray Machine and Patient Therapy: 476-5303
- Industrial Hygiene Safety: 476-6884
The Clinical and Industrial Hygiene Program assists UCSF healthcare facilities in complying with the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) requirements, conducts new employee safety orientation for hospital employees, perform industrial hygiene surveys for employees who may be exposed to hazardous working conditions, conducts x-ray machine inspections and oversees the campus sanitation program. The group also coordinates CAL/OSHA and other regulatory inspections.
SERVICES & RESPONSIBILITIES:
Asbestos Abatement Project Coordination
Provide technical support to project mangers and assists in the development of written specifications for asbestos abatement projects. Conducts inspections of asbestos abatement projects prior to the beginning of the work, verifies containment procedures during operations, and performs clearance evaluations upon completion of projects. Oversee the disposal of waste material from project site.
The Clinical Program also provide assistance to identify areas containing lead and PCBs and provides technical advice regarding their safe removal and disposal.
Asbestos Material Sampling
Conduct inspections to verify existence of Asbestos Containing Building Material (ACBM) in buildings at UCSF and maintains an inventory of all such locations. Perform material and air sampling for campus departments or upon employee request.
Asbestos Training and Notification
Develop and conduct training on the potential hazards of asbestos and safe work practices for UCSF employees who perform work that may expose them to asbestos. Notify and conduct training for all UCSF employees in areas where asbestos abatement projects are being conducted or where asbestos materials may be present in the work environment.
Facility Plans Review
EH&S staff and applicable safety officers review plans for new construction and remodeling projects to assure compliance with health and safety standards.
Inspection and Calibration of Equipment Producing Ionizing Radiation
Equipment inspection on a regular basis is required by the State Bureau of Radiologic Health Branch. Inspection records are kept by Radiation Safety and the department that owns the equipment.
Patient Care Area Monitoring
The Patient Injection Area and the Radio-pharmaceutical Laboratory are monitored daily for evidence of contamination. Brachy-therapy and thyroid therapy patient areas are monitored, and provided special instructions before release.
Occupational Exposure Monitoring
Conduct air monitoring surveys for potentially harmful chemical substances or physical agents. Investigate complaints from all UCSF locations concerning problems associated with nonradioactive chemicals, odors, and noise exposure.
Respiratory Protection Program
UCSF has developed a Respiratory Protection Program (RPP) to establish uniform policies and procedures concerning the use of respirators by UCSF employees and students. The RPP is designed to meet the regulatory requirements mandating a written respiratory protection program to assist employees, students, and supervisors in understanding their responsibilities, how to obtain a respirator, and how to properly use and care for their respirators.
Ventilation Systems Evaluation and Monitoring
Evaluate general mechanical ventilation systems for indoor environments. Monitors and evaluates local exhaust systems including but not limited to canopy hoods, slot hoods, welding booths, and spray booths.
Inspect and monitor vendor and University-controlled food service operations on campus. Prepares food handler sanitation guidelines. Coordinates the testing of the campus water supply and reviews analytical results. Investigates complaints regarding food sanitation, pest control and water quality for all campus locations.
EH&S Response Team – ERT
Coordinate operations of the Hazardous Materials ERT, provides for routine training and maintains needed equipment and supplies.
Assist the UCSF Medical Center, Langley Porter Psychiatric Institute, Mt. Zion Hospital and other off-site facilities in complying with Joint Commission on Accreditation of Healthcare Organizations (JCAHO) standards. Assists the UCSF Medical Center Infection Control Committee with the development of policies and procedures to control and prevent the transmission of infectious microorganisms.
Non-ionizing Radiation Equipment
Monitor the use and function of non-ionizing radiation-producing equipment. Lasers on campus are inspected upon installation and on an annual basis. Microwave ovens can be inspected upon request. Non-ionizing energy-producing equipment is inspected on request.