Business Policies and Procedures Manual
Chapter 60: Personnel

BPPM 60.38

For more information contact:
   Radiation Safety Office
   509-335-8916
   Environmental Health and Safety
   509-335-3041

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Forms:

• Departure Notice
• Area Evaluation/Release

Policy

Users of radiation machines, radioactive materials, hazardous chemicals, Drug Enforcement Administration (DEA) controlled substances, and/or biohazardous materials and the employing departments are responsible for ensuring that such materials are appropriately disposed of before the users terminate University employment or leave the University for more than 90 days. (See Exception for Sources of Ionizing Radiation below for the exception for radioactive materials.) Employees and/or departments are to clear areas (e.g., laboratories, classrooms) of debris and contamination prior to transfer of ownership. Such cleanup safeguards the health and safety of personnel and students reoccupying the area, prevents delays in renovation schedules, and minimizes costs to the unit. Departments are responsible for the decontamination of department-owned or -used equipment prior to transfer of ownership.

Disposal

Employees and/or departments are to remove equipment, supplies, products, and materials such as apparatuses, gas cylinders, medical waste containers, sharps containers, sharps (e.g., needles, razor blades), trash, absorbent material, and other miscellaneous laboratory or shop materials prior to vacating the area. Refer to SPPM 5.66 for disposal procedures for hazardous chemicals, including U.S. Drug Enforcement Agency (DEA) controlled substances. Refer to SPPM 4.24 for disposal procedures for biohazard materials. Refer to SPPM 4.25 and 4.26 for disposal procedures for sharps and glass waste. Refer to SPPM 9.60 and 9.70 for disposal procedures for radioactive materials.

Transfer

Hazardous materials not disposed of are to be properly transferred to other users or institutions. Contact the Radiation Safety Office or Environmental Health and Safety (EH&S) for transfer procedures.

Radiation User

An authorized radiation user must inform the Radiation Safety Office (RSO) of his or her intention to terminate his or her authorization to use radioactive materials and radiation machines (see Notification below).

Laboratory Closure

If the laboratory is being closed, the Laboratory Safety Manual, chemical inventories, and training records must be transferred to the department administrator.

Maintenance and Cleaning

Employees and/or departments are to ensure that physical, chemical, biological, and radioactive hazards have been removed prior to releasing the area to Facilities Services, Operations or new occupants. Employees and/or departments are to perform the following maintenance and cleaning tasks prior to departure:

• Remove visible residues, standing liquids, loose particulate material, and quantifiable radiological hazards.

  If radioactive materials are involved, perform appropriate laboratory surveys (see SPPM 9.30).

• Ensure that the fume hoods, cabinets and drawers are free of hazardous materials and are washed with mild detergents, e.g., soap and water. Use a 10% bleach solution to clean surfaces in laboratories where biological materials have been used. Use acid/alkaline neutralizers for acid or caustic spill areas.

Follow laboratory standard operating procedures (SOP), if applicable. See the Laboratory Safety Manual.

Decontaminate equipment (e.g., refrigerators, freezers, shelves, drawers, bench tops), floors, surfaces of local exhaust enclosures (e.g., fume hoods, biological safety cabinets), and other potentially contaminated surfaces.

Attach an Item Evaluation form if the equipment is to be relocated or surplused (see BPPM 20.77). If the equipment is to be surplused, also attach a Surplus Property Report (see BPPM 20.76). Note: Items must be certified as clean in order to be surplused. Items which are not certified as clean should only be relocated if the recipient is fully aware and capable to receive contamination on or in the transferred equipment. Coordinate with EH&S and/or the RSO regarding contaminated items which need to be released for repair or service. Decontamination of certain items (e.g., ductwork, drain traps, pumps, vacuum lines) may be difficult because of access limitations. If applicable, identify all inaccessible and potentially contaminated items on an Area Evaluation/Release form. Contact EH&S and/or the RSO for assistance. Biosafety cabinets and BSL-3 laboratories require professional decontamination. Contact the Office of Research Assurances; telephone 509-335-9553; or EH&S; telephone 509-335-3041 for assistance. If radioactive materials are involved, perform appropriate laboratory surveys (see SPPM 9.30). The RSO performs the necessary confirmatory surveys. The RSO attaches a copy of the confirmatory survey on each piece of equipment which is to be released for unrestricted use.

• Clean all work surfaces with mild detergents, e.g., soap and water. Use a 10% bleach solution to clean surfaces in laboratories where biological materials have been used. Use acid/alkaline neutralizers for acid or caustic spill areas.

  Follow laboratory standard operating procedures (SOP), if applicable. See the Laboratory Safety Manual.

• Remove the laboratory safety sign from the plexiglass holder at the entrance to the laboratory. The RSO removes radioactive materials stickers and signs from the door area. The Office of Research Assurances removes biosafety signs and stickers from the door area.

Exception for Sources of Ionizing Radiation

An authorized user of radioactive materials or radiation machines or both who plans to be on sabbatical or otherwise away from WSU for more than 90 days, but who plans to return, may transfer responsibility for the management of his or her radioactive materials, procedures, equipment, and facilities to another authorized user. That individual acts as a surrogate user and acts on behalf of the authorized user and the department. The surrogate user is responsible to the RSO for the radiation safety aspects of the transferred authorization. The department appointing authority or his or her designee must approve and submit written notice of the transfer of authority to the RSO. (The responsible appointing authority is usually the area administrator, e.g., dean.)

Notification

Department

The department chair or supervisor is responsible for notifying the responsible appointing authority or designee of a user’s planned departure date.

Deadline

Notification should occur as soon as the department becomes aware of the departure and at least one month prior to the departure date.

Appointing Authority

The appointing authority or designee is responsible for notifying the Radiation Safety Office and/or Environmental Health and Safety of an impending departure.

Departure Notice Form

Complete and route a Departure Notice to notify the Radiation Safety Office and/or Environmental Health and Safety of an upcoming departure.

User Lists

Each quarter the Radiation Safety Office provides administrators with current lists of users of radioactive materials.

Final Evaluation / Release

Following the decontamination of work surfaces and the removal of chemical, physical, biological, and radiological hazards, the appointing authority evaluates the area prior to releasing the area to Facilities Services, Operations or new occupants. Note: Decontamination of certain items (e.g., ductwork, drain traps, vacuum lines, pumps, etc.) may be difficult because of access limitations. The appointing authority or designee may release an area containing inaccessible and potentially contaminated items. Contact EH&S and/or the RSO for assistance. The appointing authority or designee must do all of the following:

• Complete an Area Evaluation/Release form.

  If applicable, identify all inaccessible and potentially contaminated items on the Area Evaluation/Release form.

• Post a copy of the completed form at the entrance to the area.
• Submit copies of the completed form to EH&S, mail code 1172, and the RSO, mail code 1302.

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Revisions:  Jan. 2021 (Rev. 560); April 2006 (Rev. 277); Aug. 1993 – new policy (Rev. 92).