Organization and Policies Handbook
Wake Forest University School of Medicine
Updated May 2005

ENVIRONMENTAL HEALTH AND SAFETY

I.          Policy

The Environmental Health and Safety office (EH&S) administers and maintains programs for:

o         the surveillance, prevention, and control of hazards that could lead to occupational injuries and/or illnesses,

o         Compliance with federal, state, and local safety, health and environmental regulations, laws and guidelines.

II.                 Purpose

The purpose of the Environmental Health and Safety office is to:

¨      develop procedures and best practices, and

¨      provide direction and consultation which promotes a work culture of safety, health, and sound environmental practices.

III.               Scope

The scope of the program includes, but is not limited to, biological safety, chemical safety, radiation safety, construction and facilities safety, fire and life safety, infection control, laser safety and environmental protection.  These programs extend to all faculty, staff, and students and to all campuses.

IV.                Procedure

A.     The Responsibilities of the EH&S are to:

1.      Oversee the functional areas of Environmental Management, Industrial Hygiene, Fire and Life Safety for statutory and regulatory compliance requirements including education, monitoring, and record keeping.

2.      Facilitate the recommendations of the General Radiation Safety, Medical Radiation Safety, Biosafety, and the Chemical Safety Committees in the development and implementation of policies and procedures.

3.      Participate in the development, review, and approval of all policies and procedures related to environmental health and safety.

4.      Direct the surveillance of potential hazards and infections and facilitate reporting, as appropriate.

5.      Obtain and maintain records for all environmental and safety permits.

6.      Direct and facilitate all inspections by environmental health and safety regulatory agencies.

7.      Disseminate pertinent environmental health and safety information to appropriate departments, programs, operations, and affiliates.

8.      Conduct new employee orientation, annual employee education and special programs to comply with environmental health and safety regulations and accreditation requirements for specific groups.

9.      Establish guidelines to fulfill regulatory requirements for environmental health and safety compliance and control of environmental hazards in the design, construction, or remodeling of new/existing facilities, including establishment of new clinical, office, classroom, dormitory, and laboratory research facilities.

10.  Establish guidelines to fulfill regulatory requirements for environmental, health and safety compliance and control of environmental hazards in the demolition or destruction of facilities, including abatement of hazards, such as asbestos.

11.  Establish guidelines and develop emergency response programs to fulfill regulatory requirements for the control of environmental hazards occurring from accidents, injuries, or other events.

12.  Make recommendations to address EH&S regulatory requirements related to patient care protocols and experimental research applications/policies.

13.  Annually review the scope and effectiveness of Environmental Health and Safety programs by reviewing the inspection, surveillance, and injury/illness

14.  Recommend corrective action based on occurrence reports of injuries, infections, and/or other potential hazards among patients and personnel.

B.      The authority for the environmental health and safety program is delegated to the director of environmental health and safety.  This includes decision making authority concerning environmental health and safety control measures in the following matters:

1.      The development and review of protocols and procedures dealing with aspects of environmental health and safety and related committee activities.

2.      The approval for purchase, access, storage, transport, use, and disposal by any employee or group, any radioactive, chemical, infectious or biohazardous materials by any employee or group.

3.      The inspection of any area of WFUSM or its affiliates for the purpose of determining compliance with laws and regulations and determining the root cause of the accident, injury or illness; any environmental accident, or indoor air quality accident.

4.       The entry into any area of the school or its affiliates for the purpose of investigating employee or public complaints or collecting chemical, biological, environmental, or physical data and samplings.

5.       The restriction of an employee, student, volunteer, or contracted services and personnel from job duties/activities due to occupational injuries and occupational or personal illnesses and/or infections.

6.      The evacuation of any room, space, area, building, or property in the event of fire, smoke, or explosion or the release of a chemical, biological, or radiological event.

7.      The review and approval of the design, building, renovation and demolition project plans prior to construction or destruction, and monitoring construction or destruction to facilitate compliance with regulatory requirements.

8.      The preparation of corrective action reports and recommendations regarding unsafe work practices identified or other operations which have statutory and regulatory requirements.

9.      The preparation of reports/documents in response to inspections or written inquiries from regulatory or other environmental health or safety agencies/organizations.

10.  The preparation and submission of licenses, registrations, and permit applications.

11.  The review and approval of specifications for asbestos and lead removal and repairs, underground storage tank registration, removal, and environmental investigation.

12.  The receipt, recording, investigation, and maintenance of records of faculty, staff, student, and visitor injuries and illnesses.