I. PURPOSE

To establish requirements and responsibilities for the proper decontamination or other proper safeguarding when maintenance, repair, equipment relocation or surplus operations occur.

II. POLICY

Instruments, equipment and areas that are contaminated with hazardous chemicals, radioactive materials or infectious materials can pose a hazard to untrained, unprotected persons. Such contamination must be properly removed, minimized or appropriately safeguarded prior to maintenance, repair, equipment relocation or surplus operations. Failure to follow the policies and procedures outlined in this document could lead to disciplinary action, up to and including termination.

III. SCOPE

This Standard Practice applies to all personnel and facilities of the University for which appropriate protective measures, training and protective equipment do not exist to safely deal with contaminated equipment or areas, and to all surplus operations that involve containers or equipment that have come into contact with hazardous materials.

IV. REFERENCES

A. OSHA Standard, 29 CFR 1910.1200 Hazard Communication
B. OSHA Standard, 29 CFR 1910.120 Haz-Waste Operations and Emergency Response
C. General Duty Clause

V. PROCEDURE

All instruments, equipment or work areas must be decontaminated prior to any maintenance, repair, equipment relocation or surplus operation whenever reasonably possible. Administrative controls such as encapsulation or remote operations are required as the next line of defense when decontamination is not reasonably possible. Appropriate hazard notice must be provided to those who will perform the maintenance, repair or similar work when decontamination is not made.

A. A "Decontamination Statement," (Form 205a) must be completed by the person (or designee) making the request for service, equipment relocation or surplus.

B. Decontamination of areas/equipment must be accomplished by at least the following:

1. The item/area to be serviced must be cleaned of all visible residue and encrusted material whenever reasonably possible.

2. Where there is the potential for hazardous non-visible chemical contamination, it may be necessary to use pH test strips, peroxide test strips or other indicating mechanism to verify that no contamination is present.

3. For items used with radioactive materials, no radioactivity must be detected with survey equipment or swipe tests.

4. Where infectious materials were used, disinfect all surfaces with an effective disinfectant.

5. Remove or deface all hazard warning labels or signs once hazards have been successfully removed by decontamination. Remove gross contamination and maintain appropriate hazard warnings when decontamination is not reasonably possible. The word "residue" may be added to indicate that only residue remains.

6. A Decontamination Statement (Form 205a - copy attached) must be completed and attached to the item/area. Forward a copy to Safety and Environmental Health.

7. If service is requested and initiated on an item/area and it appears that decontamination or other measures are not adequate to protect involved persons, the requestor will be contacted to rectify the remaining hazard(s). Costs associated with decontamination or other protective action will be the responsibility of the requestor.

Note: Adequate protection may be provided by decontaminating only the part of an item needing service or by packaging items so that persons handling the equipment will not come into contact with the contamination. A Decontamination Statement form must still be completed and posted, and a copy must be forwarded to Safety and Environmental Health when such protective measures are used.

8. Items that have been in contact with hazardous chemicals, radioactive substances, or infectious materials and are intended for sale as surplus property must be decontaminated and a Decontamination Statement form must be attached to the item(s). A copy of the Decontamination Statement must be forwarded to Safety and Environmental Health berfore the equipment is moved. Items that cannot be decontaminated must be disposed of in a proper manner.

Exception: Items of high surplus value that cannot be decontaminated may be sold under certain conditions. An example of such an item would be the sale of laboratory equipment to another laboratory. Contact Safety and Environmental Health for evaluation of such issues on an individual basis.VI. RESPONSIBILITIES

A. Safety and Environmental Health will:

1. Ensure that the requirements of this Standard Practice remain current with applicable regulatory directives.

2. Coordinate/consult with departments on non-routine decontamination issues.

B. Supervisors shall:

1. Ensure that requirements of this Standard Practice are being followed in their work area by conducting reviews, spot checks and other warranted follow-up action.

2. Plan for the necessary funding to ensure proper decontamination is occurring.

3. Initiate corrective action for deficient items noted in their area of supervision.

4. Ensure that adequate training be provided and documented.

C. Personnel shall:

1. Follow the requirements of this Standard Practice.

2. Report any problems or unsafe practices to their supervisor.

This Standard Practice is approved.

Decontamination Statement Instructions on the bottom of this certificate must be completed before service or transfer of this item/area. Piece of Equipment/Area: Department: ____________________ Serial #/Room #: Building: _______________________ Contaminant(s): Decontaminated: Yes No Decontamination Method Used: _________________________________________________________________ _________________________________________________________________________________________ If not decontaminated, how will personnel be protected? The equipment/area listed above has been decontaminated, or protection provided as described above. Name (print): Signature: Date:____________ Attach the completed certificate to the item/area decontaminated, and forward a copy to Safety and Environmental Health, FAX 777-4132/Box 9031.

Instructions

Instruments, equipment or work areas must be certified as being free from potentially hazardous contamination prior to maintenance or repair by untrained, unprotected personnel or appropriate safeguards must be established and communicated to those involved with the operation. The means to protect personnel must be included on the certification form when decontamination is not reasonably possible. A decontamination form 205a must be included with all surplus containers and equipment whenever hazardous material contamination was a factor.

• The item/area to be serviced must be cleaned of all visible residue and encrusted material whenever reasonably possible.

• Where there is the potential for hazardous non-visible chemical contamination, it may be necessary to use pH test strips, peroxide test strips or other indicating mechanism to verify that no contamination is present.

• For items used with radioactive materials, no radioactivity must be detected with survey equipment or swipe tests.

• Where infectious materials were used, disinfect all surfaces with an effective disinfectant.

• Remove or deface all hazard warning labels or signs once hazards have been successfully removed by decontamination. Remove gross contamination and maintain appropriate hazard warnings when decontamination is not reasonably possible. The word "residue" may be added to indicate that only residue remains.

• A Decontamination Statement (Form 205a - copy attached) must be completed and attached to the item/area. Forward a copy to Safety and Environmental Health.

• If service is requested and initiated on an item/area and it appears that decontamination or other measures are not adequate to protect involved persons, the requestor will be contacted to rectify the remaining hazard(s). Costs associated with decontamination or other protective action will be the responsibility of the requestor.

Note: Adequate protection may be provided by decontaminating only the part of an item needing service or by packaging items so that persons handling the equipment will not come into contact with contamination. A Decontamination Statement form must still be completed and posted, and a copy must be forwarded to Safety and Environmental Health when such protective measures are used.

• Items that have been in contact with hazardous chemicals, radioactive substances or infectious materials and are intended for sale as surplus property must be decontaminated and a Decontamination Statement form must be attached to the item(s). A copy of the Decontamination Statement must be forwarded to Safety and Environmental Health berfore the equipment is moved. Items that cannot be decontaminated must be disposed of in a proper manner.

Exception: Items of high surplus value that cannot be decontaminated may be sold under certain conditions. An example of such an item would be the sale of laboratory equipment to another laboratory. Contact Safety and Environmental Health for evaluation of such issues on an individual basis.