Title Page
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Document No.
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Audit Title
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Client / Site
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Conducted on
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Prepared by
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Location
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Personnel
General Inspection Information
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Address
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Lab Room Number
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Principal Investigator
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Biosafety Permit Number(s)
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Containment Level
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Audit Date
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Auditor
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PI Signature
Physical Requirements - CL1
Laboratory Location & Access
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Is the lab separated from public areas by a door (3.1.1)
Containment Perimeter
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Is all biohazardous waste autoclaved or treated with disinfectants? (3.7.11)
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Please provide the location of the autoclave that is used.
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If windows that can be opened are present in the lab, are they protected by screens? (3.2.1)
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Are the openable windows that do not have screens always kept closed?
Laboratory Services
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Are hooks provided for lab coats at the lab entrance? (4.5.6)
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Are street and laboratory clothing areas separated?
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Are handwashing sinks available in the lab?
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Is liquid soap provided?
Operational Procedures - CL1
Training
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Is a documented procedural (safety) manual available for all lab personnel?<br><br>Note: It is acceptable to use the Laboratory Safety Training Manual prepared by EHS, however, lab specific procedures should also be documented.
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Are its requirements followed?
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Have all lab personnel attended the Lab Safety Training presentations hosted by EHS?
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In addition to the training mentioned above, have all lab personnel received lab-specific training on the potential hazards associated with their own research and the necessary precautions to prevent exposure to infectious agents and the release of contained material?
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Have records of this training been maintained?
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Have all persons entering the containment area been trained on the operational protocols for the project in process?
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Do all persons entering the containment area know the operational protocols for the project in process?
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Are all persons entering the containment area following the operational protocols for the project in process?
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Are trainees accompanied by a trained staff member?
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Are visitors also provided with training and/or supervision commensurate with their anticipated activities in the containment area?
Emergency Procedures
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Do procedures require that all spills, accidents, or exposures to infectious materials and losses of containment must be reported immediately to the lab supervisor?
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Do these procedures also require that, when applicable, an SFU incident report form is filled out and sent to EHS?
Access
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Is access to laboratory limited to authorized personnel (e.g., laboratory staff, maintenance staff, and other persons on official business)?
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Are the doors to the lab kept closed?<br><br>Note: This does not apply to an open area within a laboratory.
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Are entry/exit protocols written, posted and followed?
Housekeeping
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Is eating, drinking, smoking, storing of food, personal belongings, or utensils, applying cosmetics, and inserting or removing contact lenses prohibited in the laboratory?
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Is oral pipetting of any substance prohibited?
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Is long hair required to be tied back or restrained so that it cannot come into contact with hands, specimens, containers or equipment?
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Are open wounds, cuts, scratches and grazes required to be covered with waterproof dressings?
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Are laboratories clean and tidy?
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Is storage of materials that are not pertinent to the work and cannot be easily decontaminated (e.g., journals, books, correspondence) minimized?
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Is paperwork and report writing kept separate from such biohazardous materials work areas?
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Is the laboratory working with a virus for which a vaccine is available?
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Is the vaccine offered to employees free of charge?<br><br>Note; Please contact EHS for a copy of the Vaccination form.
Safe Operating Procedures
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Is it required that hands must be washed after gloves have been removed?
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Are hands required to be washed before leaving the laboratory?
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Are hands required to be washed after handling materials known or suspected to be contaminated?
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Are leak-proof containers required to be used for the transport of infectious materials within facilities (e.g., between labs, to the autoclave room).
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Have traffic flow patterns from clean to dirty areas been established? (i.e. move from least to most contaminated areas)
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Are they adhered to?
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Is the use of needles, syringes and other sharp objects strictly limited?<br><br>Notes: <br>1. Caution should be used when handling needles and syringes to avoid auto-inoculation and the generation of aerosols during use and disposal. <br>2. Needles should not be bent, sheared, recapped or removed from the syringe; they should be promptly placed in a puncture-resistant sharps container before disposal.
Personal Protective Equipment
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Is protective laboratory clothing (including lab coats), properly fastened, required to be worn by all personnel?
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Does this include visitors, trainees and others entering or working in the laboratory?<br>
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Is suitable footwear with closed toes required to be worn at all times in the lab?
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Is it clear that protective lab clothing must not be worn in non-lab areas (e.g., lunch room)?
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Does the system for clothing storage ensure that lab clothing is never stored in contact with street clothing?
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Where there is a known or potential risk of exposure to splashes or flying objects, is eye and face protection used?
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Is the need for eye and face protection highlighted in all procedures for which there is a potential risk of exposure to splashes or flying objects?
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Are gloves (e.g., latex, vinyl, co-polymer) required to worn for all procedures that might involve direct skin contact with biohazardous material or infected animals?
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Are gloves are to be removed when leaving the laboratory?
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Are gloves required to be decontaminated with other laboratory wastes before disposal?
Decontamination Procedures
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Are work surfaces required to be cleaned and decontaminated with a suitable disinfectant at the end of the day?
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Are work surfaces required to be cleaned after any spill of potentially biohazardous material?
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Are there any work surfaces that have become permeable (i.e., cracked, chipped, loose) to biohazardous material?
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Has the affected part of the lab been shut down until the permeable work surface has been replaced or repaired?
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Are all contaminated materials and equipment leaving the laboratory for servicing or disposal appropriately decontaminated and labelled?
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Are these materials contained in such a way as to prevent the release of the contaminated contents during removal?
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Are all contaminated materials, solid or liquid, decontaminated before disposal or reuse?
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Is this material contained in such a way as to prevent the release of the contaminated contents during removal?
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Are disinfectants effective against the agents in use made available at all times within the areas where the biohazardous material is handled or stored?
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Name the disinfectant(s).
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Is contaminated clothing decontaminated prior to laundering?
