RS104 Laboratory Closeout

Objective

To assign primary responsibility for the closure of research laboratories to the department to whom the space has been assigned and to detail the procedure for properly closing a lab that may result from:

  • Change in ownership.
  • Change in location.
  • Loss of faculty member through relocation, retirement, loss of funding or death
  • Lab renovation

Scope

This shall apply to all research laboratories on the Memphis campus of the University of Tennessee Health Science Center. This shall apply to all students, faculty, and staff on the Memphis campus of UT Health Science Center.

Roles

  1. Department Head, Facility Supervisor, or Departmental Safety Officer shall:
    • Assign a Responsible Person for each lab that is to be decommissioned at least one month prior to decommissioning. Unresolved checklist items must be resolved by the department either by their effort or expense if outside vendors must be contracted to address issues.
    • Ensure all applicable portions of the lab closure checklist have been executed.
    • Coordinate any unresolved issues that remain in the space after the departure of the occupant.
    • Keep the completed and signed original Lab Closure Checklist for Lab Closeout and Lab Move in the department personnel files for a minimum of 10 years and send an electronic copy of the forms to the Office of Research Safety Affairs (RSA).
  2. Responsible Person shall:
    • Be a person with capable skill and knowledge to carry out the required tasks as determined by the Department Head/Facility Supervisor, in most cases the occupant or PI.
    • Ensure that all required elements of the Decommissioning Procedure are fulfilled and sign the Lab Decommissioning Checklist upon completion.
    • Shall ensure that all required signatures are obtained.
  3. Office of Research Safety Affairs (RSA) shall:
    • Coordinate with a licensed contractor to remove and properly dispose of Hazardous Waste in accordance with state and federal regulations. Shall coordinate with the PI or designate to ensure that biological hazards are either destroyed, transferred (either internal or external to the University), or safely stored in accordance with federal, state, local, and/or institutional standards.
    • Shall perform an exit evaluation of the laboratory to verify that all affected working surfaces and equipment has been cleaned and surface disinfected as prescribed by the Institutional Biosafety Officer.
    • Shall coordinate decontamination of equipment prior to moving if indicated by risk assessment.
    • Shall provide laboratory signage, labels, and other postings as appropriate.
    • Shall keep an electronic copy of the completed and signed Lab Decommissioning Form for a minimum of 10 years.
  4. Radiation Safety Office (within the Office of Research Safety Affairs) shall:
    • Remove or move any radioactive material.
    • Survey potentially contaminated equipment.
    • Perform exit survey.
  5. The Facilities Department shall:
    • Manage utilities as needed.
    • Move non-sensitive equipment and non-fixed furniture.
  6. Purchasing Services (Surplus Property) shall:
    • Remove non-sensitive equipment and non-fixed furniture that is no longer to be associated with the decommissioned lab.
  7. Outside vendors shall:
    • Remove and or transport compressed gas cylinders in compliance with state and federal regulations.

Definitions

Biological Safety Level (BSL) – A combination of laboratory practices, techniques, safety equipment and laboratory facility features employed to mitigate risk of work with biohazardous agents.

Drug Enforcement Agency (DEA) – A United States federal law enforcement agency under the U.S. Department of Justice, tasked with combating drug smuggling and use within the United States.

Department of Transportation (DOT) – A department of the United States federal government responsible for the national highways and for railroad and airline safety. It also manages Amtrak, the national railroad system, and the Coast Guard.

Departmental Safety Officer (DSO) – Departmental representative assigned to manage safety issues within the department.

Institutional Animal Care and Use Committee (IACUC) – Institutional committee responsible for oversight of the animal care and use program and its components as described in the Public Health Service (PHS) Policy on Humane Care and Use of Laboratory Animals (Policy) and the Guide for the Care and Use of Laboratory Animals (Guide).

Principal Investigator (PI) – The holder of an independent grant administered by a university and the lead researcher for the grant project, usually in the sciences, such as a laboratory study or a clinical trial. The phrase is also often used as a synonym for “head of the laboratory” or “research group leader.”

Lab Decommissioning – Lab is closing due to retirement, relocation, loss of funding, death, etc.

Lab Securing – Lab space and contents are changing ownership due to retirement, loss of funding, death, etc.

Lab Moving – Lab is being decommissioned due to relocating to another room, building, UTHSC campus or other University or everything being removed for renovation.

Lab Expansion – Lab is acquiring new space and keeping the original space.

Facility Supervisor – The Director or Head of a Center, Department or Joint Institute

Hazardous Waste – Chemical waste that is dangerous or potentially harmful to our health or the environment. Hazardous wastes can be liquids, solids, gases, or sludges. They can be unused/discarded commercial products, like cleaning fluids or pesticides, chemical reagents, or the by-products of manufacturing processes. This does not include biohazardous wastes or radioactive wastes.

Responsible Person – Individual designated by the department to oversee the decommissioning process and ensure completion of all required tasks, in most cases this is the Principal Investigator or space occupant.

Universal Waste – A category of waste materials designated as “hazardous waste”, but containing materials that are very common. It is defined in 40 C.F.R. 273.9, by the United States Environmental Protection Agency but states may also have corollary regulations regarding these materials. This includes batteries, pesticides, mercury-containing equipment, and bulbs (lamps).

Procedure

  • Notify the Office of Research Safety Affairs at least four weeks prior to the lab closeout of move.
  • Use appropriate safety controls and work practices for any cleanout activities. This includes wearing appropriate personal protective equipment (PPE) needed for the materials being handled (e.g. safety glasses, lab coat, gloves, close-toed shoes, etc.).
  • Complete the Lab Closeout Checklist
  • Secure all required signatures.
  • File the original in department personnel records and email a copy to the Office of Research
  • Safety at labsafety@uthsc.edu.

Appendices

  1. Lab Closeout Checklist
  2. Surplus Property S-3 Form

Responsible Official & Additional Contacts

Subject Matter

Office Name

Telephone Number

(xxx) xxx-xxxx

Email/Web Address

Policy Clarification and Interpretation

Research Safety Affairs

901-448-6114

labsafety@uthsc.edu

Policy Training

Research Safety

Affairs

901-448-6114

labsafety@uthsc.edu

Laboratory

Closeout

Research Safety

Affairs

901-448-6114

labsafety@uthsc.edu

UTHSC Laboratory Closeout/Move-out Checklist

Building: Room #:

Principal Investigator: Department:

Department Head,

Supervisor or Department Safety Officer: Phone #:

Responsible Person: Title: Date:

Estimated Closing Date for Laboratory:

Reason for closeout: □ Leaving UTHSC □ Retirement □ Other

Send the completed check list to Research Safety Affairs at labsafety@uthsc.edu

Item

Completed?

 

Date Completed

A. ADMINISTRATIVE

 

1. Have all recombinant DNA projects been terminated with the

Institutional Biosafety Committee? If applicable

Yes

No

N/A

 

2. Have all registered human materials projects been terminated with the

Institutional Review Board. If applicable

Yes

No

N/A

 

3. Have door placards (yellow or blue) posted to labs, hot/cold room, etc. been removed?

Yes

No

N/A

 

4. Have all animal protocols been terminated with Institutional Animal Care and Use Committee? If applicable

Yes

No

N/A

 

5. Have all registrations for use of Radioactivity been terminated with

Radiation Safety Office? If applicable

Yes

No

N/A

 

B. BIOLOGICAL SAFETY AND WASTE

 

Responsible Person Responsibilities

1. Contact Biosafety Officer (ext. 8-2054) to evaluate biohazards to be removed or discarded.

Yes

No

N/A

 

2. Unwanted biological materials must be transferred to another investigator

(MTA requires biosafety approval) or destroyed by an approved method prior to disposal.

Yes

No

N/A

 

3. All potentially infectious solid waste must be discarded in red bags, packaged for disposal in Stericycle boxes, Stericycle labels applied, and boxes removed to a pickup location.

Yes

No

N/A

 

4. All biosafety cabinets (BSCs), clean benches, centrifuges, incubators, or other equipment used to store, handle, or process potentially infectious materials must be surface cleaned and disinfected. Full gaseous decontamination of internal components of such equipment is generally not required but may be necessary depending on risk assessment. Biohazard stickers must be removed following

disinfection.

Yes

No

N/A

 

5. Properly dispose of all sharps waste.

Yes

No

N/A

 

6. Notify the Biosafety Officer of any equipment that cannot be fully decontaminated.

Yes

No

N/A

 

C. CHEMICAL SAFETY

 

UTHSC Laboratory Closeout/Move-Out Checklist (continued)

Item

Completed?

 

Date Completed

Responsible Person Responsibilities

1. Label all chemical containers with the proper chemical name. Abbreviations, chemical formulas, or structures are not acceptable.

Yes

No

N/A

 

2. If hazardous chemicals will be shipped contact a vendor to package for shipment in accordance with DOT/IATA requirements

Yes

No

N/A

 

3. Offer new, unused (but unwanted) chemicals to other PIs within the department.

Yes

No

N/A

 

4. Contact the Office of Research Safety (labsafety@uthsc.edu) to arrange for disposal of DEA controlled substances.

Yes

No

N/A

 

5. Empty all beakers, flasks, evaporating dishes, oil/water bathes into the proper container and dispose of appropriately (all hazardous materials

must be disposed of as hazardous waste).

Yes

No

N/A

 

6. Dispose of empty containers in the trash after removing or obscuring all markings and writing “EMPTY” on the container. Triple rinse empty acid containers before disposal. Empty containers which held acutely toxic chemicals must be disposed of through the Office of Research Safety. DO NOT dispose of any chemicals in the trash or down the drain, regardless of

hazard rating.

Yes

No

N/A

 

7. Check containers for expiration dates and signs of corrosion crystallization. Peroxide-forming materials must be disposed of if the container has been opened and is more than six months old, or if it has not been opened and is more than one year old. Always dispose of by the expiration date listed by the

manufacturer.

Yes

No

N/A

 

8. Contact the Office of Research Safety (labsafety@uthsc.edu) to have all remaining chemicals been identified as Hazardous Waste and scheduled for pickup.

Yes

No

N/A

 

9. Remove regulators, replace cylinder caps, and return all compressed gas cylinders to the vendor.

Yes

No

N/A

 

10. Contact the Office of Research Safety (labsafety@uthsc.edu) to arrange for disposal of any compressed gas cylinders which are non- returnable.

Yes

No

N/A

 

11. Schedule compressed gas cylinders pickup with the vendor.

Yes

No

N/A

 

12. Clean and decontaminate (e.g. soap and water, 1-10% bleach, etc.) surfaces where chemicals have been handled or stored (e.g. fume hoods, benchtops, cabinets, refrigerators, etc.). Remove all bench paper.

Yes

No

N/A

 

13. Make sure that shared equipment and locations are included in the cleanout and are decontaminated properly.

Yes

No

N/A

 

14. Notify the Office of Research Safety (labsafety@uthsc.edu) of any materials or procedures that could leave hazardous chemical residues (e.g. perchloric acid in a chemical fume hood) or areas that cannot be fully decontaminated (e.g. materials potentially containing asbestos, fume hoods, refrigerators used

in the storage of highly toxic chemicals, etc.

Yes

No

N/A

 

Office of Research Safety

1. Pickup and remove hazardous chemical waste.

    

2. Address any chemical residue hazards.

    

D. RADIOACTIVE MATERIAL AND WASTE DISPOSAL

 

Responsible Person Responsibilities

UTHSC Laboratory Closeout/Move-Out Checklist (continued)

Item

Completed?

 

Date Completed

1. Prepare radioactive waste for Radiation Safety Office (labsafety@uthsc.edu) to pick up. All waste containers must be labeled with radionucleotide and activity.

    

2. Contact Radiation Safety Officer (ext. 8-5223) for an exit decommissioning survey of the lab space and notify if there are items/equipment that may be contaminated with radioactive

materials.

    

3. Notify the Radiation Safety Officer (ext. 8-5223) if there are items or equipment that may be contaminated with radioactive materials.

    

4. Has all equipment used to store, handle or process radioactive material been declassified by the Radiation Safety Office?

Yes

No

N/A

 

5. Has all radioactive waste been properly packaged and labeled and scheduled for pick up by

Yes

No

N/A

 

Office of Research Safety (Radiation Safety) Responsibilities

    

1. Remove any radioactive materials.

    

2. Survey all equipment that is labeled or can possibly be decontaminated

Yes

No

N/A

 

3. Perform an exit decommissioning survey of the lab space and remove radiation postings from the door.

Yes

No

N/A

 

E. GENERAL SAFETY ITEMS

 

Responsible Person Responsibilities

1. Bag or box all trash and refuse (or place in trash cans and label as trash for disposal by housekeeping.

Yes

No

N/A

 

2. Have all other equipment been inventoried, S-1 form been completed and pick up scheduled with Surplus Property?

Yes

No

N/A

 

3. Has an S-3 form from Surplus Property been affixed to each equipment that will not be accompanying the departing lab?

Yes

No

N/A

 

4. Have all other materials been removed from the lab? i.e. papers, glassware, other general lab materials?

Yes

No

N/A

 

5. Notify Facilities to disconnect equipment from fixed facilities and utility connections.

Yes

No

N/A

 

Department Head, Facility Supervisor, or Department Safety Officer Responsibilities

1. Is the lab completely empty and ready for next PI to move in?

Yes

No

N/A

 

To my knowledge each of the items listed above has been appropriately addressed.

Responsible Person (Signature)

 

Responsible Person (Print)

 

Date

 

Phone #

Department Chair (Signature)

   

Date

  

Received by:

Research Safety (Signature) Date

UT Health Science Center: RS104 Laboratory Closeout

Version 2

Publication Date: 05/13/2024

S-3 Equipment (for Surplus or Relocation) Decontamination Form

Date:

Department Name:

Contact Person: Phone Number:

Item Location:

Item Description:

UT Inventory Tag Number: Serial Number:

This Equipment HAS BEEN thoroughly cleaned and contains no radioactive, chemical, or biological residues.

BIOHAZARD(S):

Not Used Used but decontaminated. Method used:

HAZARDOUS CHEMICAL(S):

Not Used Used but decontaminated. Method used:

RADIOACTIVE MATERIAL(S)

Not Used Used but decontaminated. Method used:

Statement of Safety

I certify that I, (print name) have thoroughly cleaned and/or decontaminated this equipment and tested it for radiation level, eliminating any potential hazard(s) from Bio-Hazardous Materials, Radiation, or Chemicals.

Signature: Date: (Signature of technician or designee)

Please submit a copy of completed S-3 Form(s) along with the S-1 Surplus Property Transaction Form to Surplus PRIOR to pick up by Logistics. S-3 Form(s) must be completed and approved by Research Safety Affairs. Use an individual form for each item that requires decontamination.

ATTACH ORIGINAL DECONTAMINATION FORM TO EQUIPMENT TO BE PICKED UP


RS104 Laboratory Closeout
Version: 2 // Effective: 05/13/2024
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