SA0100 - Procedure: Environmental Health and Safety

Objective

This procedure contains information and directions related to implementing environmental health and safety plans, per SA0100.

Scope

This procedure applies to all University employees.

Procedure

Risk Assessment
1. To ensure compliance with applicable standards, laws, and regulations, each environmental health and safety officer must perform a risk assessment at least once per year, to identify potential hazards that are present on their campus or institute.
2. The University’s environmental health and safety officers will ensure that they review their procedures at least 1 time per year, and will update their procedures more often, as needed.
3. The University System environmental health and safety officer will review performance metrics, and any other available data related to a campus or institute’s performance related to the applicable environmental health and safety program.
4. The University System environmental health and safety officer will ensure that an external agency assesses the University’s environmental health and safety program every 5 years.
5. Campuses and institutes are required to maintain environmental health and safety programs when and where potential risks have been identified. Such programs may include, but are not limited to:
  1. Biological Safety
  2. Chemical Safety
  3. Environmental Protection
  4. Fire and Life Safety
  5. Industrial Safety
  6. Occupational Safety and Health
  7. Radiation Safety
EHS Officer Roles and Responsibilities
1. The UT System EHS officer will:
  1. Advocate for each campus/institute EHS program.
  2. Develop or enhance environmental health and safety-related education and training opportunities throughout the system.
  3. The identification and evaluation of potential losses to the University arising out of accidents and injuries to people and loss or damage to property.
  4. Develop and monitor all safety-related policies and procedures; and
  5. Manage monthly meetings of campus safety personnel.
2. Each campus or institute EHS officer will:
  1. Provide resources sufficient to manage the environmental, health, and safety risks inherent to its operations including oversight of fire and life safety, environmental protection programs, industrial safety, laboratory safety, biological safety, chemical safety, radiation safety, and occupational health.
  2. Cooperate with the UT System EHS officer and with EHS officers at other University campuses or institutes, as needed; and
  3. Promote safety as an institutional value through training, stakeholder engagement, constructive consultation, and advocating for best safety practices and continuous improvement.
Occupational Safety: Each campus or institute must establish plans, programs, or procedures to ensure the occupational safety of its employees promulgated through the State of Tennessee’s plan of the Occupational Health & Safety Administration (OSHA) standards codified within 29 C.F.R. § 1910 (et. seq.); 29 C.F.R. § 1926 (et. seq.); and 29 C.F.R. § 1928 (et. seq.)
Fire and Life Safety
1. Each campus or institute must establish plans, programs, and procedures to ensure that fire prevention and life safety concerns are identified, mitigated, managed, and communicated to the relevant stakeholders for further action.
2. This is essential for creating and maintaining an environment that minimizes the risk of fire occurrence and potential damage to buildings or other property, as well as reducing harmful impacts on life safety.
3. Basic areas of a Fire and Life Safety Program will include, at a minimum, 4 primary categories of consideration:
  1. Management or oversight for the inspection and service of portable fire extinguishers at each campus or institution in accordance with State of Tennessee requirements and the National Fire Protection Association Standard for Portable Fire Extinguishers (NFPA 10);
  2. Management or oversight for emergency evacuation drills to validate building emergency action plans or evacuation plans in accordance with applicable codes or campus procedures.
  3. Management of an Automated External Defibrillator (AED) Program where such devices are provided and not under the oversight of another campus or institute entity; and
  4. General fire safety risk assessments to identify and address common fire hazards in buildings and campus or institute properties. The Tennessee State Fire Marshal’s Office acts as the direct Authority Having Jurisdiction for UT System campuses or institutions. Each campus is responsible for designating a liaison to the State Fire Marshal’s Office. If the liaison is not affiliated with EHS, that person will maintain close coordination with EHS regarding fire safety issues.
4. Each campus or institute must comply with the Campus Fire Safety Right-to-Know Act of 2007 and the Higher Education Opportunity Act of 2008, maintaining a record of all fires occurring in student housing located on campus or institution property.
5. An Annual Fire Safety Report must be published as stipulated by these Acts. The Fire Safety Report may be combined with the Annual Security Report as required by the Jeanne Clery Act, which is typically published by the campus or institution law enforcement agency.
Environmental Protection: Each campus or institute must establish plans, programs, or procedures to ensure environmental protection and stewardship as promulgated by the Tennessee Department of Environment & Conservation (TDEC), and the US Federal Environmental Protection Agency (EPA) standards.
Hazardous Materials Safety: Each campus or institute will establish a program for safety handling, transporting, storing and disposing of hazardous materials as required by the TDEC/EPA; OSHA; and the US Department of Transportation. These programs must include research laboratories, academic operations, or campus or institute operations that involve hazardous materials or chemicals.
Ionizing Radiation Safety: Each campus or institute that acquires or possesses ionizing radiation sources, including radioactive materials, and ionizing radiation generating devices (x-ray radiation generating machines, accelerators, cyclotrons, etc.), or generally licensed devices must establish plans, programs, or procedures to appropriately manage these items as required by the Tennessee Department of Environment and Conservation (TDEC) and the U.S. federal Nuclear Regulatory Commission. Additionally, where applicable, the campus or institute will provide designate an employee as the radiation safety officer for the applicable campus or institute. Further, the campus or institute must establish a radiation safety committee.
Nonionizing Radiation Safety: Each campus or institute must establish plans, programs, and procedures for the safe use of nonionizing radiation including high-powered laser systems, radio frequencies (RF, including radar and microwave): infrared (IR), ultraviolet (UV) light, visible light, and magnetic fields as necessary to provide safe working or academic teaching conditions based on occupational safety requirements.
Biological Safety and Select Agents: Each campus or institute that possesses or uses biological hazards, recombinant or synthetic nucleic acids, and/or select agents or toxins (as defined in 7 CFR Part 331, 9 CFR Part 121 and 42 CFR Part 73) must designate a biosafety administrator (e.g. biosafety officer) to ensure that applicable safety and compliance requirements are upheld. The biosafety administrator must establish plans, programs, or procedures covering the safe and responsible use, storage, and disposal of biological hazards. Where applicable, the biosafety administrator will establish an institutional biosafety committee (IBC) for the oversight of research involving recombinant and synthetic acid nucleic acid molecules.
Programs for Minors in Laboratory Spaces: Pursuant to Safety Policy SA0550, each campus or institute must ensure plans are in place for minors participating in safety programs and in laboratory spaces.
Reporting and Managing Safety Concerns: Each campus or institute must develop a written plan or procedure for identifying, reporting, managing, and escalating safety concerns and findings.
Training: Each campus or institute will establish training guidelines and requirements for campus employees and students to ensure compliance with all state and federal regulations and to inform individuals of the hazards present in their workplace or academic environment. Campuses or institutes must maintain records of training, including the date(s), topic(s), and format (in-person or virtual).
Environmental Health and Safety Records: Campuses or institutes must implement systems for maintaining records for safety, health, and environmental protection based on the requirements of the various regulatory agencies, best management practices, or other University policies (FI0120, SA0150, etc.)

Penalties/Disciplinary Action for Non-Compliance

In the event of any cited violation by federal, state, or local regulatory agencies, immediate notification and proposed remedy of the same shall be made to the respective campus, college, or institute safety administrator and/or responsible official as well as the University of Tennessee system safety officer.

Responsible Official & Additional Contacts

Subject Matter	Office Name	Name of Contact	Phone Number	Email
Policy Official	UT System	Mike Gregory	865-974-5028	Mike.gregory@tennessee.edu
Policy Clarification	UT Knoxville	Brian Ranger	865-974-5084	branger@utk.edu
Policy Clarification	UT Chattanooga	Brett Fuchs	570-656-3180	brett-fuchs@utc.edu
Policy Clarification	UT Southern	Shane Desquin	850-519-1149	sdesguin@utsouthern.edu
Policy Clarification	UT Martin	Charles Jahr	731-881-7583	cjahr@utm.edu
Policy Clarification	UT Health Science Center	Tim Barton	901-448-7374	tbarton4@uthsc.edu
Policy Clarification	Institute for Public Service	Tomi Rogers	803-466-0787	tomi.rogers@tennessee.edu