Guidance for Laboratory Relocation of Hazardous Materials

Boston University
Boston Medical Center

Guidance for Laboratory Relocation of Hazardous Materials

Prepared by:

Environmental Health & Safety (EHS)

Table of Contents
Purpose
Scope
Roles and Responsibilities
General Move Coordination Tasks
Hazardous Materials

Section I: Radioactive Materials and Equipment

Radioactive materials Checklist

Section II: Hazardous Chemicals and Associated Equipment

Hazardous Chemicals Checklist

Section III Biological Materials and Associated Equipment

Biological Materials Checklist

Section IV Controlled Substances

Controlled Substance Checklist

Appendix: 1 Equipment Labeling
Appendix: 2 Labeling Biohazardous Materials
Glossary of Terms
References

1. Purpose

Boston University and Boston Medical Center (BU/BMC) are committed to providing a safe and healthy work place to its employees, visitors and the surrounding community. This guide has been developed to assist all personnel involved in the relocation of hazardous laboratory materials in accordance with appropriate regulations and policies at BU/ BMC. The successful transfer of hazardous materials from one laboratory to another location and decommissioning of the vacated laboratory requires thorough planning, coordination and management by multiple parties that will assume a variety of specific roles and responsibilities. This document is intended to facilitate collaboration between EHS and the laboratory PI and staff involved in the relocation of a laboratory, coordinate their efforts specifically focusing on the transfer of hazardous materials and any equipment associated with these materials.

The movement of hazardous materials from laboratories relocating at BU/BMC can range in scope from a large move across or between campuses, a transfer between buildings on the same campus, or a transfer within the same building. While this document is written to encompass moves of the largest scale, this document can still assist with moves of a smaller scale. The Environmental Health and Safety Department Safety Advisor (EHS DSA) assigned to your laboratory can help customize the contents of this document to meet the needs of a particular move. Depending on the nature of the hazardous material, EHS will assist directly with packaging and transfer to assist the laboratory facilitate the movement and safe transfer of the material.

As described in the contents of this document, the movement of hazardous materials is a collaboration between the laboratory staff, EHS, BU/BMC Facilities and external contractors (when necessary). While the movement of the hazardous materials is owned by the laboratory PI and staff, EHS will provide assistance and technical expertise to the laboratory as needed at all stages of the move process. The checklists in this document detail step-by-step processes which include about how the above mentioned groups will interact, document references, and contact information to help facilitate the movement of hazardous materials.

2. Scope

This guide applies to all faculties, staff and contractors involved in the process of relocating and decommissioning a laboratory at BU/BMC.

2.1.Roles and Responsibilities

2.2.Environmental Health and Safety (EHS)

• EHS is responsible to:
  • Ensure that hazardous materials are packaged and transported in compliance with Federal, state and local regulations
  • Review contractor compliance, history, and performance (where applicable)
  • To provide technical assistance with regard to policies, procedures, regulatory issues, and area inspections through one or more Department Safety Advisors
  • Provide pre and post move area inspections of both the old and new locations
  • Assist in coordination and monitoring of the transfer of hazardous materials
  • Assist, in certain cases, with the packaging of hazardous materials
  • Respond to spills and emergencies that occur during the moving process

3.2 EHS Departmental Safety Advisor

• Departmental safety advisors are responsible to:
  • Provide technical assistance regarding policies, procedures, and, regulatory issues in all cases
  • Review equipment and areas that have been decontaminated and provide decontamination certification forms and stickers as necessary
  • Provide area inspections and follow up

3.3 Principal Investigator (PI)

• The PI is responsible to:
  • Designate a Move Coordinator
  • Obtain written approval for the move from the Dean, Department Head and if necessary, the Provost or other Administrative leadership
  • Contact Space Management in Facilities to inform them of the move and obtain approval of move from the appropriate University committee and/or regulatory officer
  • Secure funding for the move
  • Ensure that all of the required steps necessary for conducting safe laboratory transfer and decommissioning are completed
  • Coordinate and oversee the movement of laboratory equipment, supplies, materials, and hazardous materials
  • Ensure that committee approvals, RIMS updates, and other documentations involved with the move are completed in a timely manner
  • Ensure that vacated laboratory spaces are free of hazards and are decontaminated
  • Restoring the vacated space to a condition that allows for it to be reassigned to others for use. This includes but is not limited to insuring that the space is free of materials, equipment and waste.

3.4 Move Coordinator

• The Move Coordinator is responsible to:
  • Assist the PI in ensuring that all of the required steps necessary for conducting safe laboratory transfer and decommissioning are completed
  • Coordinate all aspects of moving hazardous materials as assigned by the PIPrincipal Investigator View Boston University's policy on...
  • Closeout of all documentation involved with the move
  • Provide assistance to the EHS Department Safety Advisor (DSA)
    Note: The move coordinator may also be the Laboratory Safety Coordinator

3.5 Laboratory Safety Coordinator (LSC)

• LSCs are responsible to:
  • Act as a point of contact for the DSA
  • Assure that all activities within their designated area occur in a safe and compliant fashion

3.6 Facilities Management

• Facilities management is responsible to:
  • Determine if the physical transport of the hazardous materials can be done with facilities personnel. If not, they will assist in getting the appropriate moving companies to bid through Procurement
  • o Move laboratory equipment that has been appropriately decontaminated and identified to be moved by the Project Manager or PI

3.7 Office of Procurement

• The Office of Procurement is responsible to:
  • Assistance in the procurement of contractors

3.8 External Contractors

• It is the responsibility of any external contractor:
  • To comply with all BU/BMC, federal, state, and local regulations as pertains to the movement of laboratory equipment, supplies, materials, and hazardous materials
  • Provide the services that they are specifically contracted to perform

4 General Move Coordination Tasks

The following is a general outline of broad tasks and responsibilities necessary for the movement of hazardous materials involved in the relocation of laboratories. The specific sections and appendices of this document provide detailed information concerning the movement of chemicals, biological agents, controlled substances, and radioactive materials.

Pre Move:

During the Move:

Post Move:

Hazardous Materials

The following sections and appendices of this document describe detailed tasks for the movement of the following materials:

• Radioactive Materials and Associated Equipment
• Hazardous Chemicals and Associated Equipment
• Biological Materials and Associated Equipment
• Controlled Substances

Section I Radioactive Material and Associated Equipment

The following section is a guide to assist in the process of moving radioactive materials (RAM) and contaminated or potentially contaminated equipment. This process must be followed when authorized Laboratory Personnel transfer radioactive material including sealed sources. Prior to the planned move minimize your order receipt of radioisotopes. All RAM waste must be disposed of by Environmental Waste Management. RAM waste will not be moved. RAM will be transported by an approved radioactive material contractor (RMC) or internal radiological safety professional upon permission from Radiation Safety Officer (RSO). All RAM must be stored in a complaint manner in the new facility. The Radiation Safety Committee, RSO and EHS will work with the laboratory to ensure that the transfer of RAM is approved and performed in accordance with policies and procedures of BU and BMC.

General Information

1. Contact the Radiation Safety Officer (RSO) at 617-638-7050 phone or @bu.edu to discuss the type and scope of move.
2. All types of radioactive waste(s) must be disposed of prior to moving. Contact the University Hazardous Waste Management group for pickup online at www.bu.edu/ehs/services/waste/radioactive-waste/.
3. All radiological stock solutions, samples, and sealed sources should be secured in such a manner as to prevent spillage, theft or loss. Any container, such as boxes, into which RAMs are placed must be labeled appropriately.
4. Submit a request for decommission for equipment and/or lab space online.
5. Radiological safety professional must be contacted to ensure proper decontamination of all areas and equipment prior to the move. See www.bu.edu/ehs/programs/laboratory-safety/laboratory-decontamination-anddecomissioning/.
6. RSO must determine that all radiological equipment to be moved is free of removable contamination.
7. All equipment destined for disposal must be determined to be free from contamination by Radiation Safety. Initial removable and fixed contamination surveys should be completed by laboratory staff. Final release survey will be performed by Radiation Safety.
8. Radiation Safety must decommission any fixed equipment or laboratory spaces that are vacated prior to cleaning, renovation, demolition, or occupancy.

Radioactive Materials/Equipment Move Checklist

Pre-Move

During the Move:

Post Move:

Section II Hazardous Chemicals and Associated Equipment

The following section is a guide to assist in the process of moving hazardous chemicals and associated equipment. Please note that the process outlined below is intended to be followed and at no time are unauthorized persons to transport hazardous chemicals and associated equipment and must not do so. In planning your move please be sure to minimize your purchase of hazardous chemicals prior to the move.

General Information

1. All hazardous chemical waste must be disposed of by the University’s hazardous waste contractor prior to move. Hazardous chemical waste will not be moved. Schedule a hazardous waste pickup online at Hazardous Waste Pickup Request: CRC.
2. All hazardous chemicals and associated equipment will be transported by an approved chemical contractor (CC) or approved individuals.
3. All hazardous chemicals that are moved must be stored in a compliant manner in the new location. NOTE: Hazardous chemicals and associated equipment must never be abandoned in laboratory.
4. Fume hoods must be decontaminated to assure they are free from chemical contamination. NOTE: Inform DSA if perchloric acid, radioisotopes, and/or toxins have been used in fume hoods as special procedures must be followed for these cases. All equipment and laboratory areas associated with hazardous chemicals must be appropriately decontaminated and labeled. See
5. Remove all regulators from compressed gas cylinders and replace with safety caps.Laboratory Decontamination and Decommissioning
6. Do not move gas cylinders, arrange for movement with the appropriate contractor.
7. Liquid nitrogen must be moved by the appropriate contractor.
8. All highly reactive or unstable chemicals such as perchloric acid, sodium, peroxide formers etc. must be moved by an appropriate contractor.
9. Do not move any mercury containing materials such as thermometers or manometers, contact EHS Environmental Management for assistance.

Chemical Materials/Equipment Checklist

Pre-Move:

During the Move:

Post Move:

Section III Biological Materials and Associated Equipment

The following section is a guide to assist PIs in the process of moving biological materials and associated equipment. The process below outlines the steps to move biological materials between laboratory locations within a campus. A Biological Materials Transport Contractor must be used to transfer biological materials between destinations at BUMC and CRC campuses as well as to transfer biological materials to other off site destinations which may include BU and BMC affiliates located off campus. Biological materials outlined in this guide include Risk Group 1 and Risk Group 2 agents (detailed definitions of these agents can be found in chapters 2-4 of the biosafety manual). Movement of Risk group 3 and 4 agents as well as Select Agents requires specialized procedures and paperwork and requires the notification and approval of the Biosafety Officer and the IBC, and possibly the responsible official and the CDC.

General Information:

1. Biohazardous materials must be transported by two knowledgeable persons (either laboratory personnel or contractors).
2. Appropriate engineering controls (biosafety cabinets) must be used if necessary and PPE must be worn (gloves, laboratory coat, safety glasses or goggles, masks or face shields) when actively handling biohazardous materials during packing and unpacking at new location.
3. At a minimum, all laboratory materials must be transported in a secondary container that is gasket sealed, shatterproof, and leak-proof. Materials should never be carried in hands or pockets.
4. The secondary container should be closeable and easy to decontaminate; an absorbent pad (or similar material) should be placed inside the secondary container to absorb any spills.
5. All containers containing biohazardous materials must have appropriate labeling See Appendix 2.
6. Both active cultures and frozen biological materials may be moved if approved by the DSA; however transportation will vary depending on the Risk Group of the materials involved Laboratory Decontamination and Decommissioning
7. Freezers may be moved with biohazardous material intact for moves that are internal to BU property, but they must be packed by the laboratory prior to being moved by BU Facilities or a move contractor. Note: Any biohazardous materials that will be transported on or across city property must be packaged according to DOT regulations, and therefore must be removed from the freezer and packaged accordingly.
8. All empty space within the freezer must be must be filled with packing material to prevent the biological materials from moving during transit.
9. All refrigerators and incubators must be emptied of all contents and appropriately decontaminated. DO NOT transfer biohazardous materials in incubators.
10. During transport of biohazardous materials, appropriate PPE (as determined based on type of move))such as a disposable lab coat should be worn over street clothes, but gloves and other PPE should not be worn. PPE should remain available in case of spills.
11. Persons involved in transport must take with them spray bottles (recommend 2X 1L) of an approved disinfectant for the materials to be transported, such as fresh 10% bleach solution (0.5% sodium hypochlorite solution); sufficient absorbent material to disinfect and remove spills; and sufficient large plastic bags (not red biohazard bags) to contain used absorbent materials.
12. After packing, actual transport of biohazardous materials must be completed within a timely manner . The container should be transported directly to the new laboratory, and not taken to offices, cafeterias, or other public locations.
13. Stocks should be immediately transferred to appropriate storage at new location and remain there until original freezer is in place and has returned to stable temperature.
14. Equipment used with Biological Materials (any equipment affixed with a biohazard sticker) will require disinfection and labeling prior to moving See Laboratory Decontamination and Decommissioning
15. All Biosafety Cabinets (BSC) that are moved must be decontaminated prior to moving and recertified in the new area. Laboratory Decontamination and Decommissioning
16. All equipment that has been decontaminated must be properly labeled prior to move. See Appendix 1 and Laboratory Decontamination and Decommissioning
17. Locations in which biological materials had been manipulated must be thoroughly decontaminated once vacated. See Laboratory Decontamination and Decommissioning
18. *All animals will be transported by LASC or LACF. Please submit a transfer request form to LASC or LACF for evaluation of the transfer and approval of the receiving location. All animals must be moved into facilities of the same or higher Biosecurity status. In some circumstances, SPF (specific pathogen free) rodents may require quarantine, testing, and/or rederivation as part of the move. Only ABSL 1 or ABSL 2 level animals can qualify to be transferred. No rodents can be transferred into ABSL3 or ABSL4 housing unless they have completed a full quarantine and testing program and/or rederivation and have been approved for transfer by LASC.
19. 19. *Cell lines or other biological materials that will be used in rodents can only be transferred if they meet the requirements in the IACUC policy on the use of Biologic Materials in Rodents.
20. 20. *Laboratories that have been identified to harbor rodent pathogens or adventitious agents might be required to undergo a more extensive decontamination process for all equipment and other materials being moved.

*Specific to Animal Transfer

Biological Materials/Equipment Checklist

Pre-Move:

During the Move

Post Move

*Specific to Animal Transfer

Section IV Controlled Substances

The following section outlines the process of moving Controlled Substances. A controlled substance is generally a drug or chemical whose manufacture, possession, or use is regulated by the Drug Enforcement Agency (DEA). DEA regulations and BU/BMC policies must be followed explicitly when moving Controlled Substances. Plan for moves in advance, and avoid ordering new controlled substances to minimize the amount in the laboratory’s inventory prior to the move.

Controlled Substance Checklist

Pre-Move:

Appendix 1 Equipment Labeling

Every piece of decontaminated laboratory equipment requires a “Decontamination Record” label prior to move. The following describes the appropriate label to be used. These labels may be obtained from the EHS Departmental Safety Advisor (DSA) after completing the Equipment Decontamination Certification Form. Note: This label is good for 15 days only, so coordination and pre-planning is important.

1. Decontamination Record Label-

Appendix 2 Labeling Biohazardous Materials

All Biohazardous materials must be labeled with the Biohazard label. Label information must include the identity of the biological material or agent, the universal biohazard symbol, and the sending and receiving laboratory identification (e.g., PI name and room number).

Each individual container must have enough label information to identify its contents. Other information should be on the outside of the package.

Biohazard Label

1. Glossary of Terms

BMTC: Biological Materials Transport Contractor: Vendor contracted to transport biological materials and associated equipment to new location after preparation by Biological Materials Contractor or the laboratory.

BSC: Biosafety Cabinet: Ventilated cabinet which uses variety of combinations of HEPA filtration, laminar air flow and containment to provide personnel, product or environmental protection or protection of all components against particulates or aerosols from biohazardous agents.

BSL2: Biosafety Level 2: Specific degree of safe laboratory practices and facility design associated with the use of biohazardous materials in Risk Group 2 as described in Section IV of “ in Microbiological and Biomedical Laboratories,” 5th edition, 2007.

BSL3: Biosafety Level 3: Specific degree of safe laboratory practices and facility design associated with the use of biohazardous materials in Risk Group 3 as described in Section IV of “ in Microbiological and Biomedical Laboratories,” 5th edition, 2007.

BSO: Biosafety Officer: BSO is primarily responsible for implementing and overseeing the campus Biological Safety Program.

BUA: Biological Usage Authorization: BUA is issued to laboratories at BU/BMC doing research with biological materials by EHS and the BU/BMC Institutional Biosafety Committee.

CC: Chemical Contractor: Vendor contracted to prepare chemicals and associated equipment for transport.

CSA: Controlled Substances Authorization: CSA is issued to laboratories at BU/BMC with controlled substances as defined by the Drug Enforcement Agency.

CSO: Controlled Substances Officer: CSO is primarily responsible for implementing and overseeing the campus Controlled Substances Program.

DSA: Department Safety Advisor: EHS personnel assigned to a laboratory to act as the primary contact person regarding all EHS activities.

LASC: The Laboratory Animal Sciences Center, responsible for animal husbandry on the Boston University Medical Campus and Boston Medical Center.

LASF: The Laboratory Animal Care Facility, responsible for animal husbandry on the Charles River Campus.

LSC: Laboratory Safety Coordinator: A person assigned by the principal investigator to serve as a point of contact for EHS in the laboratory.

MO : Move Coordinator: Person assigned by laboratory to serve as point of contact for Facilities Management and DSA and who will coordinate all aspects of moving hazardous materials for his or her laboratory.

MSDS: Material Safety Data Sheet: Document containing details of hazards associated with a given chemical and that gives information on its safe use.

PI: Principal Investigator: Person who directs a research project or program at BU/BMC. PI is responsible for all research personnel as well as safety in his or her laboratory.

RG1: Risk Group 1: Risk assessment assigned to biomaterials not considered hazardous to healthy persons.

RG2: Risk Group 2: Risk assessment assigned to biomaterials associated with human disease that is rarely serious and for which preventive or therapeutic interventions are often available.

RSO: Radiation Safety Officer : individual primarily responsible for implementing and overseeing the campus Radiation Safety Program.

2. References:

7.1 BU Policies

Biosafety Manual
Chemical Hygiene Plan
Laboratory Decontamination and Decommissioning Program

7.2 BU Committees

Institutional Biosafety Committee
Institutional Animal Care and Use Committee
Laboratory Safety Committee
Radiation Safety Committee