PDF Version of Form
for Self Assessment

1. Lab employees using ( human blood / unfixed human tissue / human cell cultures ) have taken online Bloodborne Pathogens Training in past 12 months
2. Biosafety cabinet has been certified in past 12 months
3. At least one sink is equipped with soap and paper towels
4. An appropriate disinfectant is available

5. Hazardous waste is properly stored ( closed / labeled / secondary containment / segregated )
6. Sharps disposed in appropriate containers ( labeled / puncture-resistant / not over-filled )
7. Radioactive waste is properly stored ( closed / labeled / secondary containment )
8. Radioactive waste has log attached to the container that notes date(s) and activity level(s)
9. Biological waste is autoclaved/chemically disinfected before disposal, or placed in burn box as appropriate for waste type
10. Waste generators (radioactive or chemical) have taken online training
11. Chemical spill kit is immediately available
12. Waste Disposal Guidelines are posted in room
13. Satellite accumulation area sign is posted near point of hazardous chemical waste generation

14. A Chemical Hygiene Plan with SOPs has been prepared with a copy submitted to DES
15. Lab workers have taken online Chemical Hygiene training
16. Lab workers have received training from the PI concerning safety and emergency procedures
17. Material Safety Data Sheets are available for all hazardous materials in the lab
18. A chemical segregation strategy has been implemented to separate incompatible chemicals
19. Chemical storage appears acceptable (describe problems in Remarks)
20. Corrosive chemicals are not stored above eye level
21. Chemical containers are ( intact / labeled / closed )
22. Gas cylinders are properly restrained to prevent tipping or falling
23. Peroxide-forming chemicals are dated when opened and disposed when expired
24. Personal protective equipment used by lab workers is appropriate (describe problems in Remarks)
25. Lab workers using respirators are enrolled in the UM Respiratory Protection Program (ID purpose in Remarks)
26. Necessary emergency drench apparatus ( shower / eyewash ) is available and accessible
27. Emergency eyewash is tested at least weekly
28. Electrical connections and equipment are in serviceable condition (describe problems in Remarks)
29. Electrical access panels are unobstructed
30. Food and beverages are not ( consumed / stored ) in the laboratory
31. Research apparatus that is connected into facility systems have been reviewed by FM (describe problems in Remarks)
32. Fume hoods are ( not cluttered / unaltered by users )
33. Emergency Response Guidelines are posted in the lab
34. Hazard warning signs at entrances to laboratory are ( installed / current )

35. ( Exits / aisles / fire extinguishers / fire alarm pull stations / sprinklers ) are unobstructed
36. Materials are not stored/placed within 18" of sprinkler heads
37. Lab occupants have not made modifications to the facility structure
38. No more than 10 gallons of flammable/combustible liquids are stored outside flammable liquid storage cabinets
39. ( Refrigerator / freezer ) used for storage of flammable/combustible liquids/gases is appropriate
40. Combustible materials are stored away from heat sources (describe problems in Remarks)
41. Exit ( signs / lights ) are functioning properly
42. Gas cylinder storage is not excessive (describe problems in Remarks)

43. The Caution Radioactive Material sign is posted
44. The MDE Notice to Employees is posted
45. Radioactive materials are present only in authorized areas (describe materials/locations in Remarks)
46. Doors to rooms with radioactive materials are locked when lab personnel are not present
47. Personnel using radioactive materials have received required training
48. Personnel using radiation-producing devices have received required training
49. Laser Warning Signs are ( posted when laser is in use / available / de-posted when laser is off )
50. Personnel operating lasers have received required training
51. Appropriate laser eyewear is ( used / available ) by personnel in laser area
52. Operating procedures are posted at the laser

53. Are any of the following biological toxins present in the lab: Abrin / Botulinum neurotoxins / Conotoxins / Diacetoxyscirpenol / Ricin / Saxitoxin / Shigatoxin / T-2 Toxin / Tetrodotoxin / Staphylococcal enterotoxins / Shiga-like ribosome inactivating proteins / Clostridium perfringens epsilon toxin

54. Check box if an Electron Microscope is in this facility

55. Describe any (type, wavelength, power) lasers that are known to be in the lab that have potential for users to be exposed to the beam:

56. Describe general nature of work conducted:

57. What does the PI/Lab Manager believe is the lab's greatest hazard:

58. What additional safety efforts/initiatives does the PI/Lab Manager feel DES should initiate:

59. Remarks/Special Hazards/Housekeeping Issues: