Program Administration and Standard Operating Procedure
Program Administration
The LSP is administered through four core elements:
- Implementation and Oversight
- Documentation
- Recordkeeping
- Continuous Improvement
Together, these elements support consistent application of laboratory safety requirements and ongoing regulatory compliance.
Implementation and Oversight
The LSP establishes the framework for implementing and maintaining safe laboratory practices. Applicable policies, procedures, and safety controls shall be consistently implemented and enforced throughout University laboratory operations.
Program Documentation
Current SOPs, safety manuals, equipment inventories, and supporting laboratory safety guidance shall be maintained to support safe laboratory operations.
The LSC recommends and reviews laboratory safety policies, procedures, and controls. EHS maintains the official LSP and document control system, including revision dates and version numbers.
Recordkeeping
Required laboratory safety records shall be created, maintained, and retained in accordance with applicable regulatory and University requirements. Records may include:
- Safety training
- Laboratory inspections
- Exposure monitoring, when applicable
- Incident reports
- Corrective actions
Recordkeeping shall support compliance with applicable OSHA requirements, including the Laboratory Standard (29 CFR 1910.1450) and Hazard Communication Standard (29 CFR 1910.1200).
Periodic Review and Continuous Improvement
The LSP shall be periodically evaluated and updated to remain current and effective. Reviews consider regulatory changes, program performance, audit findings, incident trends, and recognized laboratory safety practices. The LSC shall meet at least annually to review the effectiveness of the LSP, University laboratory safety policies and recommend improvements as appropriate.
Standard Operating Procedures
SOPs provide task-specific instructions for activities involving hazardous materials, equipment, high-risk processes, or other laboratory activities requiring additional controls. SOPs identify hazards and establish the controls and procedures necessary to minimize the risk of exposure, injury, or environmental impact.
SOPs should be developed using the University SOP template and must be appropriate to the specific laboratory activity. Applicable SOPs shall be incorporated into laboratory safety training and made readily accessible to personnel performing the work.
Required Standard Operating Procedures
Laboratory-specific SOPs are required when activities involve:
- Hazardous materials or equipment requiring additional controls.
- High-risk or non-routine processes, including significant energy sources, pressurization, heating, cryogenic operations, flammable or explosive materials, or complex reactions.
- New materials, equipment, or processes identified through a hazard or risk assessment.
- Activities with significant risks, incidents, or near-misses that require additional controls.
- Activities specifically identified as requiring an SOP by the LSP, EHS, or applicable regulations.
Elements of SOPs
As applicable, laboratory-specific SOPs should include:
- Purpose and scope
- Roles and responsibilities
- Hazard identification and risk assessment
- Required engineering controls and PPE
- Safe operating procedures
- Emergency and spill response
- Waste disposal requirements
- Applicable training requirements
SOPs should be laboratory- and task-specific rather than relying solely on generic procedures.
Storage, Review and Approval
SOPs shall be reviewed by the responsible Faculty/PI, EHS and approved by the Department Chairperson or designee before implementation. Applicable personnel must review and acknowledge SOPs as part of their training.
SOPs shall be readily accessible to affected personnel and reviewed periodically to ensure they remain current. Updates may be required following changes in procedures, materials, equipment, regulations, incidents, audit findings, or identified deficiencies.
Routine Laboratory Practices and Manufacturer Documentation
A separate written SOP may not be required for routine laboratory techniques or equipment when the activity does not involve particularly hazardous materials, high-risk operations, or institution-specific safety controls beyond those addressed by the LSP.
In these cases, personnel shall follow generally accepted laboratory practices and current manufacturer instructions or operating documentation. The Faculty/PI is responsible for determining whether these resources adequately address the activity and ensure appropriate training and supervision.
When appropriate, EHS may allow manufacturer documentation to serve as the primary operating document when supplemented with institutional requirements addressing, as applicable:
- Authorized users
- Required PPE
- Emergency shutdown
- Incident reporting
- Waste disposal
- Training documentation