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Environmental Health and Safety and Risk Management

  • Responsible Office: Safety and Risk Management, Division of Administration
  • Current Approved Version: 10/06/2016
  • Policy Type: Administrative

Policy Statement and Purpose

It is the policy of Virginia Commonwealth University (VCU) to maintain a healthy and safe campus and to conduct all university-related activities in compliance with applicable requirements for health and safety from federal, state, and local agencies. Observing campus health and safety policies and procedures is the responsibility of every member of the university community. Supervisors have an elevated responsibility to ensure that all individuals under their direction have the necessary knowledge, skills, and training to perform or participate in university-related activities. Safety and Risk Management (SRM) is the designated department at VCU in charge of administration of and compliance with health and safety regulations and is charged with providing mandatory training as required to meet these regulations. Training content is described in “Related Documents.”

SRM is charged with providing a safe environment for all individuals at VCU. This includes developing applicable policies and procedures and performing inspections to monitor for compliance. As necessary, SRM shall provide recommendations for corrective action to address deficiencies and mitigate risks to the university community. Recipients of a request for corrective action are expected to correct deficiencies in a timely manner. SRM is responsible for reporting deficiencies and recommendations to the appropriate levels within the university to ensure issues are addressed in a timely manner. In instances of immediate threat to the health and safety of the university community, SRM shall require operations within the affected area to cease until issues are resolved and the area is deemed safe through inspection or appropriate approval from federal, state, and local authorities.

Noncompliance with this policy may result in disciplinary action up to and including termination. VCU supports an environment free from retaliation. Retaliation against any employee who brings forth a good faith concern, asks a clarifying question, or participates in an investigation is prohibited.

Who Should Know This Policy

Faculty, staff and students are responsible for knowing this policy and familiarizing themselves with its contents and provisions.

Definitions

Immediately Dangerous to Life and Health
Immediately dangerous to life and health is the occurrence of an unsafe activity or operation not in accordance with all applicable requirements for health and safety or the VCU health and safety procedures and that poses an immediate life-threatening danger to the university community.

Minor Noncompliance
Minor noncompliance is the occurrence of an unsafe activity or operation not in accordance with all applicable requirements for health and safety or the VCU health and safety procedures and that does not pose an immediate life-threatening danger to the university community, but which violates license or permit requirements or any other related university policy or expectation.

Major Noncompliance
Major noncompliance is the occurrence of an unsafe activity or operation not in accordance with all applicable requirements for health and safety or the VCU health and safety procedures and that does not pose an immediate life-threatening danger to the university community, but which violates regulatory requirements and which can reasonably be considered to represent a life-threatening danger to the university community in the near future.

Contacts

The Office of the Assistant Vice President for Safety and Risk Management officially interprets this policy. The Assistant Vice President for Safety and Risk Management is responsible for obtaining approval for any revisions as required by the policy Creating and Maintaining Policies and Procedures through the appropriate governance structures. Please direct policy questions to the Assistant Vice President for Safety and Risk Management.

Policy Specifics and Procedures

SRM will perform routine and unannounced inspections to determine compliance with health and safety policies and procedures. SRM shall document identified deficiencies, provide recommendations, and request corrective action plans from the appropriate supervisor of the area. The following sections describe appropriate inspection and notification steps after minor noncompliance, major noncompliance, or immediately dangerous to life and health deficiencies are identified. If a regulatory agency and/or license condition requires a more stringent response to correct a violation, the principal investigator and SRM will follow the more stringent requirement.

  1. MINOR NONCOMPLIANCE: If a minor noncompliance deficiency is noted, SRM shall respond as follows.
    • Send an electronic notification (e-mail) to the supervisor or principal investigator within five calendar days of completing inspection, listing deficiencies and recommendations for corrective actions.
    • Work with the supervisor or principal investigator to develop a reasonable corrective plan that ensures the safety of the university community and satisfies all applicable requirements.
    • Conduct a follow-up inspection within 30 calendar days to ensure corrective actions are implemented.
    • Send an electronic notification to the chair or director of the unit, requesting a correction plan and expected completion date if deficiencies are not corrected.
    • Conduct a second follow-up inspection within 30 calendar days to ensure corrective actions are implemented.
    • Send an electronic notification to the dean or vice president of the unit requesting a correction plan and expected completion date if the deficiency is not corrected.
    • Conduct a third follow-up inspection within 30 calendar days to ensure corrective actions are implemented.

After receiving the notification from SRM, the supervisor or principal investigator (and the chair or director of the unit, and the dean or vice president, if necessary) shall respond as follows.

    • Attest that all corrective actions recommended by SRM are implemented.
    • Coordinate with SRM to provide re-training on the health and safety procedures, if necessary.
    • SRM will refer the noncompliance findings and request for corrective actions to the appropriate cabinet level member for additional action if the corrective actions are not implemented.

  1. MAJOR NONCOMPLIANCE: If a major noncompliance deficiency is noted, SRM shall respond as follows.
    • Send an electronic notification to the supervisor or principal investigator within five calendar days of completing inspection, listing deficiencies and recommendations for corrective actions.
    • Work with the supervisor or principal investigator to develop a reasonable corrective plan that ensures the safety of the university community and satisfies all applicable requirements.
    • Conduct a follow-up inspection within 30 calendar days to ensure corrective actions are implemented.
    • Send an electronic notification to the chair or director of the unit, requesting a correction plan and expected completion date if deficiencies are not corrected.
    • Conduct a second follow-up inspection within 30 calendar days to ensure corrective actions are implemented.
    • Send an electronic notification to the dean, or vice president of the unit requesting a correction plan and expected completion date if the deficiency is not corrected.
    • Conduct a third follow-up inspection within 30 calendar days to ensure corrective actions are implemented.
    • Refer the noncompliance findings and request for corrective actions to the appropriate cabinet level member for additional action if the corrective actions are not implemented.

After receiving the notification from SRM, the supervisor or principal investigator (and the chair or director of the unit, and the dean or vice president, as appropriate) shall respond as follows.

  • Ensure that all corrective actions recommended by SRM are implemented.
  • Coordinate with SRM to provide retraining on health and safety procedures before sending the employee back to the worksite or operation that was found in noncompliance.
  • Recommend appropriate disciplinary actions, up to and including termination of responsible person(s), if the major noncompliance was not corrected after the second notification.
  • Coordinate payment of fines incurred from regulatory agencies, when applicable
  1. IMMEDIATELY DANGEROUS TO LIFE AND HEALTH: If an issue is found that is immediately dangerous to life and health, SRM shall respond as follows.

    • SRM will direct the individuals in the area to stop the unsafe operation immediately.

    • SRM will notify the supervisor or principal investigator and Assistant Vice President of SRM. The Assistant Vice President of SRM shall notify the appropriate university officials of the risk to the university community.

    • SRM will send an electronic notification the day of the occurrence to the supervisor or principal investigator, with a copy to the chair or director of the unit, with the non-compliance findings and with a request for immediate corrective actions.

    • SRM will work with the supervisor or principal investigator to develop a reasonable corrective plan that ensures the safety of the university community and satisfies all applicable requirements.

    • SRM will conduct a follow-up inspection the next day or before the operation resumes verifying corrective actions are implemented.

    • SRM will send an electronic notification to the dean or vice president of the area if the unsafe situation is not corrected.

    • SRM will refer the case to the appropriate cabinet level member for further action.

Forms

There are no forms associated with this policy and procedures.

Related Documents

VCU Policy: Dual Use Research of Concern in the Life Sciences (DURC)

VCU Policy: Vehicle Accident Prevention and Safety

Bloodborne Pathogens – Infectious Waste

Chemical Hygiene Plan

Chemical Waste Management Plan

Confined Space Program

Hazard Communication

Laboratory Safety at VCU

Radiation Safety Guide

Respiratory Protection Program

Select Agent Program

SRM website

Worker’s Right-To-Know

Revision History

Approval/Revision Date Title

June 15, 2018 Environmental Health and Safety and Risk Management

[minor revision to Related Documents section]

FAQ

There are no FAQ associated with the policy and procedures.