Laboratory Inspection Checklist Principal Investigator: Lab Representative(s): Permit/Certificate Number(s): Inspector: Inspection Number: Date of Inspection: Room Number(s)/ Lab Designation(s): Inspection History: Deficiencies discovered last inspection (Inspection date: ) Status of Deficiency Correction 1
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? CBS 3.1.1, Describe Locking mechanism (key, card, other)? 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? 2575, CBS How (i.e. locked refrigerator, locked storage box, etc.)? 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? a. Do signs contain the required information? i. Correct symbols? Wording? (e.g. RAYONNEMENT- DANGER-RADIATION for RAM labs)? ii. Correct BIO containment level/ram laboratory classification? RPR 21, NSRDR 23, CBS 3.3.2, LSM 2.1 NSRDR 23, CBS 3.3.2 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 2
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? Emergency/Life Safety 10. Are emergency eyewash/shower facilities available as per ANSI Z358.1? NSRDR 36, 2215, RSOP 08B NL OHS Reg 42, 63, ANSI Z358.1 GD- 52, CBS 3.6.6 ANSI Z358.1 a. Is appropriate signage available? Are weekly checks conducted and documented? 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? NL FA Reg Is signage available? 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? a. Lab coat, appropriate shoes, gloves, eye protection (if necessary)? b. Are PPE donned and doffed in a manner that minimizes contamination (according to SOP)? c. Is space available for PPE storage (near the point(s) of entry)? NL OHS Act 5.2, 7, LSM 2.4, GNSCR 17, CBS 4.4.1 CBS 4.4.4 LSM 2.4 CBS 4.4.1, CBS 4.5.14, LSM 2.4 GD-52, CBS 3.3.9 3
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) 42 a. Are fume hoods cluttered or used for storage? LSM 5.3 b. Are sash height and flow failure indicators present? 45 c. Are volatile chemicals and volatile RAM used solely in the GNSCR 12, fume hood? 42, LSM 3.2 20. Are essential safety equipment on emergency power? Physical Laboratory 21. Are surfaces/furniture non-absorbent and easily GD-52, CBS decontaminated/cleaned? 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, 67 23. Is a hand-washing sink (with amenities) available for handwashing? 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 4
25. Is the laboratory clean and free from unnecessary materials (i.e. tidy) or materials that may be difficult to decontaminate? Operational 26. Have workers completed general safety training (are records available)? BIO RAM WHMIS/Lab Safety 27. Have workers received lab/job-specific training (are records available)? 28. Are workers working with RAM/BIO/CHEM safely/securely and according to policies/procedures? (observe workers) 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) 458, CBS 4.6.35 NL WHMIS Regs 5, LSM 4.1.3.1, GNSCR 12, CBS 4.3.1 LSM 4.1.3 GNSCR 17, 2917 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 CBS 4.8.3, exiting laboratory? After working within fume hood/bsc? 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, NL OHS Act BSOP, etc.) available to workers at worksite? 5.2, NSRDR 17, CBS 4.1.15 a. Is there a documented Laboratory Safety Plan? LSM 1.3.2 Notes: 5
Inspection Section B: Radiation Safety Inspection Items Requirement Ratings Comments 34. Is a properly functioning contamination meter available? 2572 35. Is an up to date wipe map available for all authorized RSOP 11 location? 36. Is contamination monitoring completed within prescribed RSOP 11 time frame (i.e. 7 days of RAM use)? 37. Are areas above "dirty" or "action" contamination limits cleaned and re-wiped and, if necessary, reported to RSO? RSOP 11, 2642 a. Do workers know contamination limits? dirty = 0.5 Bq/cm 2, MUN = 30 Bq/cm 2 (for Class C isotopes); CNSC = 300 Bq/cm 2 (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. 40. Is disposal of RAM waste approved by RSO prior to disposal? (verify with records) 41. Are containers or devices with > 1 EQ labeled appropriately (trefoil, isotope name, activity, date of measurement and form)? 42. Is thyroid monitoring/screening (> 2 MBq) or tritium bioassays (>400 MBq) required? 2575 2160, GNSCR 12 RPR 20, RSOP 08B 2046, NSRD LC-2600, RSOP 01B 43. Are radioisotopes used on humans? 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 GNSCR 14 building/taken into the field? Provide Location of posting 6
47. Are required signs/posters posted within the lab? RSOP 08B, 2570 a. CNSC/MUN containment safety poster (EQ, SS/Ins, Basic, Intermediate)? 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 PTNSR 25 certificate to expiry date) 49. Are packages received according to CNSC/MUN guidelines? PTNSR 40, Ask procedure used RSOP 06 a. Checked for damage? Reported if damaged? PTNSR 40 b. Wipe tested and dose surveyed? (review records) Reported if above limits? c. Receipt documentation retained 2 years? (review records) RSOP 06 PTNSR 31 Notes: 7
Inspection Section C: Biological Safety Inspection Items Requirement Ratings Comments 50. Is an up to date inventory available (including items stored CBS 4.10.2 outside of the CZ)? a. If stored outside CZ, is it stored in labelled, leak-proof, CBS 4.6.20 impact resistant container with restricted access? 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 CBS 4.6.24 LRA)? b. Are on-demand flames limited and sustained flames CBS 4.6.30 prohibited within BSC? 52. Are vacuum systems (if present) equipped with a filter and/or CBS 3.7.17 disinfectant trap? 53. Are the disinfectants used effective against the materials in CBS 4.8.2 use? 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 CBS 4.8.5 laundering? 58. Are autoclave monitoring/recording devices functioning and CBS 3.7.14 provide operational parameters? 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 CBS 4.3.2 work, symptoms of illness and preventative measures? 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 8
61. Is emergency response refresher training given annually and CBS 4.3.10 documented? 62. Is all training documented? (check training logs) CBS 4.10.1 63. Have any of the following occurred (ask): HPTR 5 a. increase the virulence or pathogenicity of a human pathogen 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: 9
Inspection Section D: Chemical Safety Inspection Items Requirement Ratings Comments 64. Is mercury present in the lab? 65. Are chemicals stored in proper cabinets? 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? 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)? 69. Are chemicals (used, expired or unstable) disposed of correctly? (describe) 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? 450 LSM Section 5.3 Section 42.5, 58; LSM Section 5.3 71. Are chemicals labelled with WHMIS compliant labels? NL WHMIS 7.(3), 9.(1) 10
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: 11
Item # Action Items Responsible Person(s) 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. Due Date PI (print): PI (signature): Date: Inspector (print): Inspector (signature): Date: 12