550-26: Workplace Safety and Environmental Protection

Workplace safety and environmental protection are the responsibility of everyone who works at or visits UCSF. All work at UCSF must be performed in a manner that mitigates risk and promotes safety, security, environmental stewardship, and compliance with all applicable federal, state and local laws and regulations.

This policy delineates responsibilities for all UCSF employees, students, visitors, volunteers and contractors to work safely, and to identify and correct hazards in the workplace. UCSF is committed to providing a safe and healthy environment in the conduct of all University activities, and to preserving resources and protecting the environment.

Workplace Safety and Environmental Stewardship

All UCSF operations are to be conducted in compliance with applicable federal, state and local regulations, and when appropriate, with accepted environmental and workplace safety standards that promote personal safety, accident and injury prevention, and environmental protection. This Policy applies to all UCSF employees, contractors, students and visitors. The UCSF Office of Environment, Health and Safety (EH&S) has been established to assist all units and personnel in ensuring safety, protecting the environment, and complying with related laws and regulations.

Reporting Hazards

All persons who work at or visit UCSF are encouraged to report any observed health and safety hazards to their supervisors, managers, safety committees, or EH&S. There shall be no retaliation for reporting of safety concerns. Working in a safe environment that appropriately controls injury and illness risks is the responsibility and the right of everyone at UCSF.

All persons who work at or visit UCSF are encouraged to report any observed release of hazardous materials to the environment (air, water or soil) to their supervisors, managers, EH&S, or UCSF Police. Unauthorized release of hazardous materials, either accidental or intentional, are forbidden on UCSF property. EH&S has the responsibility and authority to determine if an identified release, either routine or non-routine, is allowable and/or reportable to regulatory agencies.

Workplace Safety at Remote Sites

UCSF workplace safety and environmental protection programs apply to all work performed by UCSF personnel, including work at remote sites, such as projects conducted outside of California. When making arrangements for remote work, any desired exemptions from these programs -- or special support needed from EH&S -- requires advance, written agreement from EH&S. As with all work-related injuries, those that occur during remote work must be reported to the supervisor and Disability Management Services (DMS), and serious injuries (those that require treatment at a hospital) must be immediately reported to the supervisor, DMS and EH&S.

Workplace Safety and Environmental Inspections

Supervisors and managers are should informally observe and inspect their employees’ workplace each time they enter the area, and provide coaching where appropriate. To supplement these regular, informal inspections, EH&S conducts documented, periodic inspections of workplaces to identify and address safety and environmental deficiencies within the timeframe established by EH&S. EH&S will document and communicate inspection reports, and enforce corrective action as needed. The purpose of these inspections is to:

1. Correct identified hazards and or unsafe conditions and mitigate hazards in a timely manner;
2. Ensure safety policies and procedures are being implemented properly; and
3. Provide safety guidance and technical assistance in areas such as: radiation, biosafety, fire and life, chemical, waste disposal, ergonomics, controlled substances and environmental requirements.

EH&S as a Liaison to Regulatory Agencies

EH&S, as the designated liaison to outside safety and environmental agencies, has the responsibility to maintain clear communication with environmental health and safety regulatory agencies, and to provide appropriate technical input in campus decision making and compliance strategies.

1. Regulatory agencies that impact UCSF operations include, but are not limited to, the California Occupational Safety and Health Administration, the California Environmental Protection Agency, Joint Commission on Accreditation of Healthcare Organizations, San Francisco Department of Public Health, California State Department of Health Services, and California State Fire Marshal's Office.
2. EH&S is to act on behalf of all UCSF campus sites and medical centers with regulatory agencies, in coordination with unit leaders and UCSF Legal Counsel where appropriate, regarding matters of workplace safety or environmental protection. This includes both written and verbal communications, scheduling agency visits, and coordinating responses to notices or penalties issued by regulatory agencies to any department or administrative unit. Corrective actions and any financial penalties are to be the responsibility of the affected operating unit, unless other arrangements are approved by UCSF senior executives on a case-by-case basis.
3. All correspondence received from such regulatory agencies must be immediately shared with EH&S. When representatives of regulatory agencies conduct unscheduled visits or inspections, EH&S must also be notified immediately.

All Members of the UCSF Community

All members of the UCSF community include employees, students, visitors, volunteers and/or contractors.

All work conducted at UCSF is to be performed in a manner that ensures the protection of students, employees, visitors, public, contractors, property, and the environment, and in compliance with all applicable federal, state and local laws and regulations, and UCSF policy.

All members have the ability to report hazards anonymously. Anonymous reporting can be submitted by clicking here.

Adherence to good health and safety practices and compliance with applicable health and safety regulations are the responsibility of everyone at UCSF. Responsibility begins with the individual in the workplace, laboratory or classroom, and proceeds upward through all levels of management. All members of the UCSF community must:

• Be informed of conditions that may affect their health, safety, or environment;
• Successfully complete all safety training identified as applicable by their supervisor or instructors;
• Immediately report to supervisors, instructors or EH&S any potentially unsafe practices or serious hazards in the workplace, classroom or laboratory; and
• Stop work that appears unsafe, until proper safety precautions are implemented.

Further information regarding responsibilities under Cal/OSHA can be found in the University’s Injury and Illness Prevention Program (IIPP).

Any member of the UCSF community who identifies work that may present an imminent hazard to people or the environment has authority to call for that work to cease immediately, via notification of the appropriate supervisor or EH&S. Work may proceed only when all involved parties agree that safe conditions have been established. In the event that consensus cannot be reached on safety regarding the task at hand, EH&S Safety Specialists can determine the appropriate control measures.

UCSF personnel who plan to undertake activities that require safety or environmental permits, registrations, and/or licenses must first obtain (or renew) all pertinent documentation by working with EH&S as the liaison with campus and external regulatory agencies.

Permits or other advance written approval is required for work involving the following: asbestos; biological/infectious materials; controlled substances; cooking with open flames; energized electrical systems; Class IIIB or IV lasers; explosives; hazardous waste disposal, hazardous material shipping or transport; welding or other “hot work;” incinerators; poly-chlorinated biphenyls (PCBs); preparation of food for public consumption; work with radioactive materials, waste, or radiation producing machines; or installation of above-ground tanks, underground tanks, or any equipment that produces environmental emissions. This list is not exhaustive, and EH&S must be contacted for other required permits.

Managers and Supervisors

University supervisors, including faculty, deans, department chairs and principal investigators (PIs), are responsible for protecting the health and safety of employees, students, visitors, volunteers and contractors working under their direction or supervision. These responsibilities include:

1. Being familiar with and implementing current environment, health and safety policies, practices, and programs;
2. Periodically monitoring and providing feedback on the safety of observed work practices;
3. Ensuring employees, visitors, and/or contractors have been provided with appropriate safety training and information to conduct work in a safe environment; Training is to be provided to:
   
   • All new hires in the workplace and/or laboratory
   • When a new work assignment has been given
   • When a new hazard is introduced into the work environment
4. Ensuring employees are provided with a safe work environment to perform their work tasks. This includes the provision and maintenance of equipment (including furniture, seating, accessories and other work tools) that meet UCSF, safety and ergonomics requirements.
5. Investigating injuries and other incidents to prevent recurrence; and
6. Ensuring individuals under their management adhere to and promote applicable environment, health and safety policies, practices and programs;
7. Completing applicable safety training before starting work assignments that involve hazardous materials or equipment, and to successfully completing all retraining in a timely manner.
8. Implementing appropriate environment, health and safety policies, practices and programs.
9. Providing adequate resources to ensure staff, faculty, students, visitors, volunteers and contractors working under their direction are able to conduct work in a safe environment and in compliance with policy and regulatory requirements; and ensuring workplace hazards are corrected in a timely manner.
10. Notifying EH&S when new processes or equipment are introduced to the work area that generate environmental risks, including emissions.

Safety Committees

Certain committees are responsible for establishing and enforcing UCSF-wide health and safety policies, including: Institutional Biosafety Committee, Chemical and Environmental Safety Committee, and the Radiation Safety Committee.

Departments are encouraged to establish department-specific safety committees to address concerns that are common to their line of work. Where department safety committees are established, they must meet at least quarterly, include a representative from each major sub-unit within the organization, and document their meetings and action items.

Office of Environment, Health and Safety (EH&S)

The Office of Environment, Health and Safety (EH&S) has been established to oversee, support and help enforce UCSF workplace safety and environmental protection efforts. EH&S maintains programs to:

1. Promote, train, consult, and monitor actions to protect the environment, and the safety of UCSF employees, students, visitors, volunteers and contractors.
2. Identify and enforce correction of environmental and workplace safety hazards, and encourage UCSF employees, visitors, students, volunteers and contractors to report and address hazards and/or unsafe working conditions.
3. Ensure UCSF activities are conducted in a manner protective of safety and the environment, and in compliance with all applicable safety and environmental regulations and policies.
4. Elevate any unresolved compliance issues to the department head (or higher) and the appropriate safety committee(s). EH&S has authorization to prevent work continuation until the compliance issue has been resolved.
5. Review legislation, recommend policies, and monitor compliance with federal and state environment, health and safety regulations and UC health and safety policies and programs.
6. Develop institutional environmental and safety compliance programs and assist schools, departments, faculty, managers, supervisors, visitors, and contractors with implementation.
7. Provide guidance and technical assistance to identify, evaluate, and correct environmental and safety hazards.
8. Provide safety and compliance training materials.
9. Provide guidance and technical assistance on safe use of hazardous radiological, biological, and chemical substances, including hazardous waste management and disposal services.
10. Conduct and document workplace environmental and safety inspections, and monitor and enforce appropriate corrective actions to be taken by managers, supervisors, or departments.

Please refer to the UCSF Injury and Illness Prevention Program Plan for more information. In conjunction with EH&S, the following departments also provide policies and programs that contribute towards workplace safety and environmental protection:

• Disability Management Services
  • Policy 150-24: Workers’ Compensation
  • Policy 150-26: Employee Disability/Reasonable Accommodation
  • Policy 150-28: Americans with Disabilities Act (ADA) Barrier Removal
• Occupational Health
  • Policy 550-17: Employee Health Services
  • Policy 550-20: UCSF Communicable Disease Surveillance and Vaccination Policy
  • Policy 550-21: UCSF Campus Communicable Disease Exposure Follow-up
• UCPD
  • Policy 550-23: Emergency Management
• Office of Sustainability
  • UCOP Policy: Sustainable Practices
• Facilities Services