Standard Operating Procedure

Subject Safety: Chemical Hygiene Plan

Index Number Lab-0115
Section Laboratory
Subsection General
Category Departmental
Contact Eric Bashaw
Last Revised 7/20/2018

References
29 CFR 1910.1450 Occupational Exposure to Hazardous Chemicals in Laboratories
29 CFR 1910.1200 The Hazard Communication Standard
29 CFR 1910.1030 The Bloodborne Pathogen Standard
29 CRF 1910.1312 The Personal Protective Equipment Standard

The following Gundersen Health System policies are referenced in this plan. All Laboratory staff are
expected to be familiar with these policies. When a discrepancy occurs between policies occurs consult
the Chemical Hygiene Officer or Safety Department if not available follow the stricter of the standards.

GL-9074 Respiratory Protection Plan

GL- 3300 Hazard Communication Plan
GL- 9050 Personal Protective Equipment
GL-9075 Hazardous Material Spill Response
GL- 9091 Hazardous Material and Waste Control Plan
GL-9502 Occupational Exposure to Blood and Body Fluids
GL- 9082 Safety Management Plan
GL-9079 Latex Safety Plan for Patients and Employees
GL-9063 Cryogenic Liquids

Applicable To
All employees of Gundersen Health System Laboratories

Detail
PRINCIPLE:
The purpose of the Chemical Hygiene Plan (CHP) is to establish a program ensuring that control
methodologies are implemented to prevent unacceptable occupational health exposure to hazardous
chemicals in laboratories. Furthermore, that the CHP plan is accordance with other GHS safety policies
and programs. This plan has been developed for Gundersen Health Systems. The objective is to ensure
that the proper procedures, training and written chemical hygiene plans are in compliance with all
applicable Federal, State, and Local regulations along with best practices as described by accrediting and
trade organizations.

Implementation
TOPICS:

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Contents
1.0 GENERAL PRINCIPLES .............................................................................................................................. 2
2.0 LEVELS OF RESPONSIBILITY ..................................................................................................................... 2
3.0 ROLE/FUNCTION OF CHEMICAL HYGIENE OFFICER (CHO)...................................................................... 3
4.0 EXPOSURE ASSESSMENT AND REDUCTION ............................................................................................ 4
5.0 TRAINING PROGRAM ........................................................................................................................... 14
6.0 MEDICAL CONSULTATION AND EVALUATION ..................................................................................... 15
7.0 RESPIRATOR USE .................................................................................................................................. 16
8.0 WASTE DISPOSAL ................................................................................................................................. 16
REVIEW AND CHANGES: ............................................................................................................................. 16

1.0 GENERAL PRINCIPLES

All chemicals, because of concentration, toxicity, flammability, carcinogenicity, or other characteristics,
are potential health hazards. The intent of the Chemical Hygiene Plan is to provide guidelines for
handling and using chemical without causing harm to oneself, other employees, or to the laboratory
environment.
1.1 Minimize Exposure
Even for substances with no known significant hazard, exposure should be minimized. When
working with substances which present special hazards, special precautions should be taken.
Engineering controls and personal protection equipment should be used to minimize exposures.

1.2 Avoid Underestimation of Risk

One should assume that a mixture presents all the hazards of its components. One should
assume that all substances of unknown toxicity are toxic.

1.3 General Safety Requirements

1. Smoking, eating, drinking, mouth pipetting, and application of cosmetics or contact lenses
are prohibited in the laboratory. These activities (excluding mouth pipetting and smoking) are
only permitted in the designated areas such as separate offices and break rooms.

2.0 LEVELS OF RESPONSIBILITY

2.1 The Chief Executive Officer and the Vice President of Patient Services, with the Laboratory
Administrative Committee, have the organizational responsibilities for providing continuing
support for institutional chemical hygiene and the health and safety of laboratory employees.

2.2 Laboratory Director – Ultimate responsibility for implementation of all elements of the
Laboratory Standard. Must provide continuing support.

2.3 Chemical Hygiene Officer (CHO) – Technically qualified individual designated by laboratory
management. Responsibility outlined in Section 3.0

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2.4 Laboratory Manager – Overall responsibility for chemical hygiene in the laboratory. The
Laboratory Manager must:
1. Ensure that employees know and follow the chemical hygiene rules, make sure
protective equipment is available and in working order, and training has been provided.
2. Provide regular chemical hygiene and housekeeping inspections.
3. Know the current legal requirements concerning regulated substances.
4. Determine the required levels of protective apparel and equipment.
5. Ensure that facilities are adequate and training is up to date for any new hazard
introduced into the laboratory.

2.5 Laboratory Technical Leader – Primary responsibility for the chemical hygiene procedures for
that operation. The Technical Leader must:
1. Work with laboratory management, Chemical Hygiene Officer and other
employees to develop and implement appropriate hygiene policies and
practices.
2. Monitor the procurement, use and disposal of chemicals used in the laboratory.
3. See that appropriate audits are maintained.
4. Help project directors develop precautions and adequate facilities as they apply
to the Laboratory Standard.
5. Maintain compliance to the Chemical Hygiene Plan.

2.6 Laboratory Staff – Plan and conduct each operation in compliance with the institution’s
procedures and good personal hygiene practices.
Laboratory personnel are responsible for placing warning signs and labels on chemical
containers, equipment or areas where special or unusual hazards are in use.

3.0 ROLE/FUNCTION OF CHEMICAL HYGIENE OFFICER (CHO)

Eric Bashaw, Director Environmental Compliance is the designated CHO.

The role of the CHO is to provide technical guidance in the development and implementation of the
provisions of the Chemical Hygiene Plan. The CHO will Work with administrators and employees to:
1. Develop and implement appropriate chemical hygiene policies and practices.
2. Act as a technical advisor or member of the hospital incident command in the event of any
lab emergency.
3. Works with the safety department to follow up on any incidents or near hits that are
reported.
4. Represents the laboratory on the Environment of Care committee.
5. Monitor the procurement, use and disposal of chemicals used in the area of responsibility
6. Evaluate the need for protective apparel and equipment.
7. Evaluate monitoring and maintenance of protective equipment.
8. Conduct department inspections, inventories, annual reports. MSDS and safety resources
9. Review and approve operations as stated in the Chemical Hygiene Plan that require
approval process.
10. Provide constant oversight on implementation of the Chemical Hygiene Plan.
11. Develop precautions and adequate facilities as they apply to the Laboratory Standard.

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12. Serves as a resource for training of chemical hygiene regulations and use of protective
equipment.
13. Studies current legal requirements concerning regulated substances and maintain
appropriate reference sources.
14. Annually review, evaluate and update the Chemical Hygiene Plan for area of responsibility.

4.0 EXPOSURE ASSESSMENT AND REDUCTION

4.1 Hazard Identification
Literature, including OSHA Hazard Communication Standard 29CFR 1919.1200 shall be available
through the CHO or the Safety Department.

An inventory of laboratory chemicals is taken annually. As new chemicals are added to the lab
chemical inventory, the Gundersen Health Systems safety personnel review hazards and online
hazard groups: acute toxic, reproductive toxins, and select carcinogens.

Employees may not work with hazardous chemicals until they receive adequate training. Initial
awareness training is provided at new employee orientation through the safety department and
a follow up lab safety training given within 60 days of employment.

Chemicals of an unusual or severe exposure hazard will not be used until approved by the
laboratory management or CHO, with suitable precautions outlined in the procedure.

Safety Data Sheets are stored electronically on MSDS online. The information is available on
Gladiator or by calling the Security Department in the event of a utility failure.

Good chemical labeling practices will be observed and labels on incoming containers will not be
removed or defaced. The receiving Lab section will label the chemical with date received, an
open date will be placed upon opening of all chemicals.

When materials are transferred from their original containers, the container into which the
material is placed shall be properly labeled.
1. Content and quantity, concentration or titer
2. Storage requirements
3. Date prepared or reconstituted by laboratory
4. Date opened
5. Expiration date
6. NFPA or word labels such as: acute toxin, cancer hazard, reproductive hazard,
flammable, health hazard, and oxidizer are necessary.

NOTE: The above elements may be recorded in a log (paper or electronic), rather than on the
containers themselves, providing that all containers are identified to be traceable to the
appropriate data in the log.

4.2 Chemical Procurement, Distribution, and Storage

4.2.1 Procurement
The CHO can assist in seeking safety information before initial use of new chemicals.

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All substances are delivered to Logistics. Stockroom employees check for leaks and
breakage, carefully observing hazard labeling. Chemicals are left in shipping containers.
Within 24 hours (except weekends) stockroom employees deliver the chemical on carts
to the ordering department. If questions arise relating to a chemical hazard and a SDS
sheet is not included in the shipment, these employee should access Gladiator, Top
Corporate Resources, MSDS online. Security has a backup SDS resource.
The receiving lab section will label the chemical with date received.

Any mixture of chemical used for testing must have a SDS available before sending to
the laboratory. A SDS for each component of a mixture may substitute for the mixture
SDS. It will be the role of the Chemical Hygiene Officer to assist with these processes.

4.2.2 Unattended Storerooms

The goal of all lab areas will be to work toward the segregation of chemicals, according
to their chemical classes and their compatibility. Chemicals will be stored in a well-
ventilated area with local exhaust, as appropriate. Storerooms are not to be used as
dispensing areas, preparation or repackaging areas. Under the direction of the CHO,
chemical storage rooms are monitored weekly for obstacles, spills and adequate
ventilation.

4.2.3 Distribution
Whenever chemicals are hand-carried, they are to be transported in safety bottle
carriers, or secondary containers. Avoid transporting in elevators that are occupied by
other personnel.

4.2.4 Laboratory Storage

Amounts in storage should be as small as practical. Within the lab, chemical volumes
should also be limited. One gallon of flammable and combustible liquids may be stored
on open shelving for every 100 ft2 of space. Since the Histology Lab and Cytology Lab
have automatic fire suppression systems, 2 gallons of flammable material may be stored
per 100 ft2. Up to two gallons may be stored in safety cans or safety cabinets for every
100 ft2.

Note: The Histology Lab is 1085 sq. ft.

1. 22 gallons can be stored on shelving
2. 22 gallons can be stored in safety cans or safety cabinets.
The Cytology Lab is 491 sq. ft.
1. 10 gallons can be stored on shelving
2. 10 gallons can be stored in safety cans or safety cabinets
Bench top and hood storage is not acceptable (See Note below). Exposure to heat or
direct sunlight should be avoided.

Storage requirements:
A. Acids: Separate organic acids (i.e. acetic acid) from mineral acids (i.e. nitric
acid).
B. Containers containing over 4 L should never be stored over counter height.

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C. Carcinogens: Away from work areas, labeled with a systemic pictogram.

D. Concentrated acids and caustic bases: Below counter level.
E. Dry Chemicals: La Crosse Lab – reagent room, media room, histology,
immunology.
F. Flammable liquids: Store away from oxidizing agents. Must be in approved
safety containers when possible.
G. Gas cylinders: While stored and used they must be secured to walls. When not
in use or hooked to building systems they must be capped.
H. Peroxide-producers: Storage outdate is 12 months.
Examples are aldehydes & ether.
I. Isolate perchloric acid from organic materials. Do not store on a wooden shelf.
J. Do not allow picric acid to dry.
K. Toxic materials, in general, require “Danger Poison” labeling of storage areas.
L. Hoods should not be used to store chemicals unless they are secondary
containers being used for active processes.
• Flammables cannot be sorted in a hood containing electrical equipment
or a heat source.
M. Containers: When possible, chemicals should be ordered in plastic or safety
cans. Bottle carriers are provided in all storage areas.
N. Transport: Bottles carriers are used for transporting all chemicals. Gas cylinders
are transported strapped down on dollies.

4.3 Laboratory Safety Operating Procedures

4.3.1 Working with Chemicals
The CHO and lab safety personnel will work with administrators and employees for
conducting training, chemical inventory and procurement of hazardous chemicals.
Laboratory management, CHO and lab safety personnel approval will be required for the
following operations, procedures, and activities:
A. Work with highly acute toxic materials
B. Work with carcinogens
C. Work with reproductive toxins
D. Work with a hazardous chemical new to the site
E. Work with quantities of hazardous chemicals in excess of 2-10 liters.
F. Use of (a. b. or c.) outside of a hood
G. Procedure for removal of contaminated waste from “designated areas”.
Management will provide appropriate personal protective equipment, such as eye
protection, chemical resistant gloves, respiratory equipment when necessary, and
appropriate apparel.

The laboratory worker is responsible to comply with the institutions policies and
procedures on the use of personal protective equipment, and to remove contaminated
equipment before leaving the area of use. Hazardous chemicals may never be used or
stored in areas not designated for their use.

4.3.2. Laboratory Workplace Hygiene

A. Treat all chemicals and laboratory supplies as if they are hazardous materials.

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B. Personal hygiene:
1. Avoid unnecessary exposure to chemicals by any route. Do not deliberately
smell or taste chemicals.
2. Never pipette anything by mouth.
3. No eating, drinking, and smoking in areas where chemicals are present.
4. No storage of food and beverages in storage areas and refrigerators used
for laboratory operations.
5. No use of cosmetics or lip balm in the work area.
6. Do not manipulate contact lenses in the work area.
7. Hair should be secured back and off the shoulders in such a manner to
prevent contact with hazardous chemicals and contaminated materials.
8. Hand washing is required when leaving a workspace or the laboratory area
C. Personal Protective Equipment: When working with hazardous chemicals, pair of
impervious gloves and change them frequently. Do not touch door knobs,
telephones, or computer keyboards with contaminated gloves. When leaving the
area, thoroughly wash your hands, forearms and any other skin that may have been
contaminated. Wear a long sleeved fully buttoned lab coat. If clothing becomes
contaminated, decontaminate or dispose of it before leaving the area. Wear safety
glasses or a face shield.
D. Handle and store laboratory glassware with care, inspect frequently for star cracks,
and do not use damaged labware.
E. Always consult the SDS when working with a chemical for the first time or
performing a procedure for the first time. If hazards are identified ensure that
proper steps are taking to mitigate or remove the hazards. The CHO is the resource
to contact for help.
F. Use a fume hood for operations which might result in the release of toxic chemicals,
vapors. As a rule of thumb, engineering controls need to be used when handling
any volatile substance with a TLV (Threshold Limit Value) of less than 50 ppm, or the
LC50 is less than 200 ppm, or oral LD50 (lethal dose of 50% test animals) is less than
50 mg/kg.
G. Assure that the plan for each laboratory operation includes plans and training for
waste disposal.
H. Decontamination procedures: Consider factors such as surface type, spilled
material, and the amount spilled. Remove as much chemical as possible by covering
with an absorber and scooping or carefully pouring into a waste receptacle. Follow
with a wet cleaning method (dispose rags/paper towels into hazardous waste
receptacle) or HEPA filtered vacuum (vent into a hood if possible). The vacuum bag
is disposed into the waste receptacle as determined by Gundersen Health Systems
Hazardous Material Control Plan.

4.3.3 Working with Acids and Corrosive Bases

In addition to the precautionary statements discusse3d in this section, please consult
the reference material listed in Appendix B of the standard. An extensive discussion is
presented in the National Research Council’s “Prudent Practices for Handling Hazardous
Chemicals in Laboratories”.
A. Primary routes of entry are the skin and eyes.

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B. Wear double nitrile gloves or rubber household gloves.

C. Whenever the possibility of vapors and splashing exist, use chemicals in a
fume hood.
D. Eye protection is required (goggles or shield are recommended) when
working outside of a fume hood.
E. When diluting concentrated acid, add acid to the diluent.
F. Separate acids and bases in storage. Separate organic acids (acetic) form
inorganic (nitric). Store in a special acid cabinet whenever possible.
G. Use an ice bath, or have a cold water source available, to reduce the
reactivity hazards form extremely exothermic acid/base reactions.
H. Special procedures may be required for certain extreme hazardous
chemicals, e.g., hydrofluoric nitric acids, and sulfuric acid (can produce 80oC
temperature rise when mixed with water).

4.3.4 Working with Solvents

A. Primary routes of entry are through inhalation and by skin absorption.
B. Wear double nitrile gloves.
C. Consider toxic effects of some solvents plus flammable properties. Generally,
solvents are used in a fume hood.
D. When used outside of a fume hood, consider the PEL (Permissible Exposure Limit)
and the need for respiratory protection. Goggles or face shield will be worn also.
E. Peroxide forming materials such as aldehydes and ethers must be labeled with a 12
month out date.
F. Special procedures may be required for phenol and formaldehyde. Chemical
Hygiene Plan Appendix L.
G. Do not store flammable solvents in nonflammable rated refrigerators. The light in
those refrigerators has the potential for generating sparks.
H. When transferring solvents from a metal container to another metal container. The
containers must be bonded to prevent static discharge.

4.3.5 Working with Toxins

A. Primary route of entry is inhalation, contamination of the hands, and absorption
through the skin directly or by material dissolved in solvents.
B. Avoid aerosolization, use fume hood.
C. While wearing a mask, weight out dry materials in a draft-free environment and
dissolve materials, or cover before leaving the controlled environment.
D. Wear protective gloves and eye protection.
E. Any use outside of the fume hood requires evaluation of PEL and possible need for
respiratory protection.
F. Review requirements of the SDS before working with toxic materials.

4.3.6 Working with Allergens/Sensitizers (Examples are formaldehyde, various

isocyanates, benzylic and allylic halides)
A. Primary route of entry is inhalation and skin contact.

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B. Wear appropriate protective apparel, double nitrile gloves to prevent hand contact
with allergens or substances of unknown allergenic activity. Wear appropriate
protective apparel. Double nitrile gloves are recommended.
C. For powders, handle in a draft free environment and cover the powder. 3M mask is
recommended.
D. Wash hands frequently and avoid transmission to other bare skin surfaces.
E. Store these substances, properly labeled, in an adequately ventilated area.

4.3.7 Working with Reproductive Toxins (Examples are organ mercurials, lead
compounds and formamide)
A. Primary route of entry is inhalation and skin contact.
B. Handle reproductive toxins only in fume hoods or tested engineering control
systems. An exception is when weighing powders; work in a draft free environment,
cover powder and wear 3M mask. Refer to GHS GL-9074 Respiratory Protection
Program for use of respirators or masks.
C. Use appropriate protective apparel and gloves to prevent skin contact.
D. Wash hands frequently and avoid transmission to other bare skin surfaces. Store
these substances, properly labeled, in an adequately ventilated area in an
unbreakable container.

4.3.8 Working with Chemicals with High Acute Toxicity

Examples include chloroform, cyanide, formaldehyde, phenol, mercurial, vinyl chloride,
hydrogen sulfide, nitrogen dioxide, hydrofluoric acid.
A. Primary route of exposure may be inhalation, ingestion, skin contact. Minimize
exposer by any route.
B. For powders, handle in a draft free environment and cover the powder. 3M mask is
recommended.
C. It may be necessary to trap released vapors to prevent their discharge with the
hood exhaust.
D. Always avoid skin contact and wash hands and arms immediately after working with
these materials.
E. Be aware of posters describing medical treatment procedures and be prepared to
handle accidents and spills.
F. Be prepared for accidents and spills and post a safety person nearby before
initiating process.
G. See Section 4.7 for Chemical Spills.
4.3.9 Working with Carcinogens
Lab Examples include formaldehyde and chloroform.
A. Primary routes of exposer may include ingestion, inhalation, and skin contact.
B. Always use approved engineering controls for fume hood.
C. For powders, handle in a draft free environment and cover the powder, 3M mask is
recommended. Refer to GHS GL-9074 Respiratory Protection Program for use of
respirators or masks.
D. When leaving the work area, remove protective apparel and thoroughly wash hands
and skin surfaces.

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E. Use and store breakable containers of these chemicals in chemically resistant

containers or trays whenever possible.
F. Decontaminate the work area before normal work is resumed. Decontaminate any
equipment and glassware, in the hood, before removing them.
G. Use wet methods to clean-up liquids, or for dry materials the spill team has a HEPA
filtered vacuum cleaner. Vent into the hood.
H. Assure that contingency plans, equipment and materials are available in the event
of accidents or spills.
I. Store containers only in a ventilated, limited access area in appropriately labeled,
unbreakable and chemically resistant secondary containers.

4.3.10 Working with Liquid Nitrogen

A. Protect all skin when decanting or entering a container of liquid nitrogen. Wear
thick thermal gloves or freezer gloves. Wear a face shield and long sleeved lab coat.
B. Store and use a liquid nitrogen container in a well-ventilated area.
C. The Safety Data Sheet is available on Gladiator through MSDS online. If the network
fails, contact security for the SDS.
D. A corporate policy is available on Gladiator GL-9063 Cryogenic Liquids.

4.3.11 Other Operating Procedures

The following topics are covered in Appendix C:
A. Procedures for working with compressed gases and for working at pressures
above or below atmospheric (Page 75).
B. Protective apparel, safety equipment, emergency procedures and first aid (Page
154).
C. Design requirements for and use of electrically powered laboratory apparatus
(Page 179).
D. Laboratory ventilation (Page 193).

Existing institutional procedures are incorporated into this Chemical Hygiene Plan by
reference. All are available from the CHO.
A. Bloodborne Pathogen Exposure Plan, GL-9067
B. Environmental Compliance Gladiator Home Page:
1. Waste Types
2. Laboratory
3. Laboratory Chemical List
4. Hazardous Material Spill Response Plan
5. Comprehensive Waste Reduction
6. Waste Pick up
C. Employee Exposure, GL-9502 (Blood and Body Fluids).
D. Reproductive Health Protection Program, GL-9073
E. Fire, GL-9097
F. Glove Use, see Universal Precautions, GL-9100
G. Hazardous Material (Right to Know), LG-9091
H. Isolation Precautions, GL-9100

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I. GL Emergency Preparedness Plan, Gladiator, Top Corporate resource and Red

Binder.
J. Respiratory Protection Program, GL-9074
K. Safety: Biological, Lab-0105
L. Utility Failure, Lab-0110
M. Disaster, Lab-0225
N. Terrorism Response, Lab-0226

4.4 Employee Exposure Determination and Evaluation

The goal of the chemical hygiene plan is to maintain exposure below the OSHA permissible
exposure limits (PEL), as specified in 29 CFR 1910, subpart Z, and below specified limits assigned
to “select carcinogens”. The criteria used to determine the need for additional monitoring to
evaluate the employee’s exposure include:
A. Physical and chemical properties of compound or mixture
B. Quantity used and frequency of use outside of fume hood
C. Open container vs. covered systems and potential for airborne exposure
D. Exposure controls currently in place
E. Chemical stability of the compound
F. Volatility or vapor pressure
G. Established PEL
H. Specific toxicological profile
I. Determination of potential exposure based on process risk following a review of the
above items.

If there is reason to believe a chemicals’ PEL or action level may be of concern, any previous
monitoring data and results will be reviewed. If unavailable, the Gundersen Health Systems
Safety Department and Lab Managers will coordinate the appropriate monitoring procedures
for dust or chemical vapor, work with industrial hygienists, or consultants if needed, to reduce
exposure levels and provide for continued monitoring until the recommended permissible
exposure levels are met. Retesting may be necessary when procedures, equipment or
personnel change.

The Safety Department or Manager shall provide any affected employees with monitoring
results within 15 working days of receipt. Records are maintained in Employee Health Services.

4.4.1 Periodic Testing (coordinated by Safety Department, Managers and CHO):

La Crosse chemical exposure monitoring occurs in various lab areas such as Cytology,
Histology and Parasitology labs. The La Crosse morgue is monitored for formaldehyde
exposure. Exposure assessment determines monitoring. Periodicity is driven by historic
exposure results, new chemicals or employees, work practice or process changes, and
control measure effectiveness.

A. Xylene: Badges are issued by the Director of Environmental Compliance. The

results are reviewed by the CHO and results are given to Employee Health and
Safety. Instructions are contained in the kit. The xylene OSHA limit is 100 ppm eight
hour time weighted average (TWA).

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B. Formaldehyde: Formaldehyde Standard 29 CFR 1910.1048 states that an initial

monitoring of badge TWA and air sampled short term exposure limit (STEL) shall be
repeated each time there is a change in production, equipment, process, personnel,
or control measures which may result in new or additional exposure to
formaldehyde.
1. STEL: If air monitoring exceeds the STEL of 2 ppm in 15 minutes, procedures
and/or facilities must be improved. Annual monitoring is then required
under the worst circumstances.
2. 8 hour TWA: If 8 hour TWA badge monitoring exceeds 0.5 ppm, semi-
annual testing is required. This is called the action level. 0.75 pm is the
maximum allowable level. At this level procedures and/or facilities must be
improved.
3. Continuation of monitoring: OSHA states that monitoring may discontinue
if two consecutive sampling periods taken at least seven days apart show
employee exposure is below the action level and the STEL. Gundersen
Health Systems, however, will monitor formaldehyde badges in histology
and the morgue.
4. Formaldehyde respirators: Full face piece with cartridges must be used for
procedures resulting in exposure of up to 10 ppm.
5. Formaldehyde user medical surveillance: Employees exposed to
formaldehyde will be assigned to Gundersen Health Systems Respiratory
Protection Program, coordinated by the Safety Department. That program
will select respirators, train safety, and determine the need for medical
examination. The employee will be followed annually and as needed after
exposures.
C. Other Hazardous chemicals, such as toluene or alcohol can be monitored if exposure
is a concern.

When monitoring has demonstrated that the OSHA permissible exposure limits (PEL)
have been exceeded, control procedures will be implemented as described below.
These procedures are recommended whenever handling hazardous chemicals, as
defined in the Laboratory Standard:
A. All work will be moved to a fume hood to the extent possible.
B. Hazardous chemicals will be weighed out in a draft-free environment, and
dissolved into solution before leaving the controlled area. A mask should be
worn.
C. When a fume hood situation is not possible, alternate chemicals will be
sought.
D. When alternate chemicals are not available, use of more dilute solutions will
be attempted.
E. When less dilute solutions are not possible, respirators will be utilized, after
proper training. Additional protective gowns and gloves may be necessary.
F. All extremely hazardous chemicals will be used only in designated areas or
in dilute solutions.
G. Highly acute toxic, select carcinogens, and reproductive toxins must be
handled in the designated area.

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4.5 Engineering Controls and Personal Protection Devices

Safety showers and eye washes are to be used for immediate treatment of chemical and body
substance splashes and showers for extinguishing clothing fires. Wash for 15 minutes, if
possible, and transfer the La Crosse workers to the Trauma and Emergency Center in La Crosse.
Regional employees should see their local provider and be transported to TEC if necessary.
Facility Operations checks these devices yearly or as requested. Laboratory staff performs
weekly eyewash/shower checks. Documentation will be on the “Emergency Eyewash Checklist”.
See the attached form.
Fume hoods:
A. When to use fume hoods: When heating, evaporating, mixing, or handling solvents, and
when working with chemicals with irritating or noxious vapors.
B. Only if ample hood space is available, can a hood be used for storage of hazardous
chemicals or centrifuge use. Flammables cannot be stored in a hood containing a
functional centrifuge, other electrical equipment, or a Bunsen burner.
C. Clinical Engineering performs monthly function verification of the air flow with sash
open 12 inches. Acceptable air velocity is 100 cubic feet per minute. Inoperative hoods
awaiting repair will be posted “Out of Service”.

Class II Biological Safety Cabinets:

In the La Crosse Lab, Safety Cabinets are monitored annually by a contacted vendor. Contacted
vendor reports are retained in microbiology with copies to the safety department. Function
verification is performed by Clinical Engineering as well. Files are in Clinical Engineering, ext.
52448. Decontamination is performed before maintenance by the vendor providing repair
service. Microbiology surface cleans the biological safety cabinets daily and media room
workers surface clean the laminar flow hood daily.

Eye protection (Prudent Practices, page 155)

A. Safety glasses are hardened glass or plastic with side shields. These will be worn at all
times while in laboratory work areas.
B. Face shields must be worn when protection is needed form flying particles, harmful
liquids, or autoclave steam.
C. Goggles:
1. To be used when protection is needed form chemical splash or impact.
2. Anti UV to be used when repairing UV light sources.
D. The wearing of contact lenses is not recommended in the laboratory. Danger exists in
trapped gases, vapors and splashes.

Fluid Resistant lab coats are provided for bench work and phlebotomy. Coats will be buttoned,
sleeves must cover the wrists. Plastic aprons can be used in addition to provide protection from
corrosive or irritating liquids and hot autoclave liquids or temporarily, short term if
temperatures are uncomfortable. This only applies to work situations without risk of spray,
splash or splatter. Do not use when working with flammables due to static electricity.
Laboratory coats should not be worn outside of designated areas.

Gloves: Non-talc vinyl or nitrile gloves are useful protection from biohazards and chemical
hazards. Use while performing all lab techniques and when working with hydrogen peroxide,

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and quaternary amine disinfectants. Insulated gloves are to be used when emptying autoclaves
and handling hot containers. Household latex gloves are to be used for glassware washing and
general cleaning. Thick or insulated gloves will be used for handling dry ice.

Footwear. Sturdy non-slip shoes with socks or stockings will be worn. Open toes or sandals are
not acceptable.

Fire Safety Equipment Reference Fire policy: GL-9097. Fire extinguishers are placed in all lab
facilities. An automatic water sprinkler system is installed in several labs.

The Respiratory Protection Program is described in the following documents: and GL-9074
Respiratory Protection Program. Disposable surgical masks from central supply can be used for
protection against dust and mists. Use 3M particle masks for weighing dry chemicals and
mixing. All employees using N-95 respirators or Powered Air Purifying respirators must be fit
tested and undergo medical surveillance and training before use.

4.6 Designated areas

Chemical storage areas of the lab are designated with “Danger, Chemical Hazard”. The hospital
morgue door has signage: “Authorized Personnel Only”.

In areas using select hazardous materials, the materials are labeled with the nature of the
hazards. Appropriate precautions are followed, protective equipment is provided, and training
is provided on assignment, annually, and when procedures change.
Refer to section 4.3 for handling precautions in using these chemicals.
Please contact your CHO or the Safety Department if you are uncertain about a chemical.

Fume hoods are located in the following La Crosse Lab areas:

1. Parasitology
2. Chemistry – Non Automated
3. Histology
4. Microbiology

4.7 Emergency Plan/Spill Control

For all laboratory spills the procedures listed in GL-9075 will be followed

5.0 TRAINING PROGRAM

5.1 Purpose:
To assure knowledge of the hazards of chemicals present in the work place. Training will be
provided in the following circumstances:
A. Upon the employee’s initial assignment
B. Prior to new assignments
C. Annually as refresher courses; classroom or Gladiator (internet)
D. Students when initially assigned to clinical rotation.

5.2 Content of the Training

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 Standard Operating Procedure

Employees will be trained on the contents of this written chemical hygiene plan and instructed
notice of its location and availability.

5.3 Record of the Training

Employees are required to sign the document which certifies that they have received training.
La Crosse office assistants maintain the training records of La Crosse employees.
A. Recorded by the trainer (Chemical Hygiene Officer or Manager)
B. Stored in files of EH&S and/or employee education folder
Regional managers and supervisors maintain training records for their employees.

Employee Right to Know or Hazard Communication Standard training: A copy of the standard,
29 CFR 1910.1200 can be found on the OSHA website or a printed copy can be obtained from
the CHO.

6.0 MEDICAL CONSULTATION AND EVALUATION

Medical consultation and medical examinations: The employer shall provide all employees who work
with hazardous chemicals an opportunity to receive medical attention, including any follow-up
examinations which the examining physician determines to be necessary, under the following
circumstances:
A. Whenever an employee develops signs or symptoms associated with a hazardous chemical to
which the employee may have been exposed in the laboratory, the employee shall be provided
an opportunity to receive an appropriate medical examination.
B. Where exposure monitoring reveals an exposure level routinely above the action level (or in the
absence of an action level, the PEL) for an OSHA regulated substance for which there are
exposure monitoring and medical surveillance requirements, medical surveillance shall be
established for the affected employee as prescribed by the particular standard.
C. Whenever an event takes place in the work area such as a spill, lea, explosion or other
occurrence resulting in the likelihood of a hazardous exposure, the affected employee shall be
provided an opportunity for an Employee Health Services consultation. Such consultation shall
be for the purpose of determining the need for a medical examination.

Employee Health Services consultations will be performed by members of EHS under the direct
supervision of the director. The employee, CHO, or manager may make the appointment.

After consulting with the employee health nurse, the employee may seek a medical examination at the
suggestion of the employee health nurse or on their own.

The consultations and medical examinations will be provided without cost to the employee, without loss
of pay, and at a reasonable time and place.

The employer shall provide the following information to the physician:

A. The identity of the hazardous chemical(s) to which the employee may have been exposed.
Include an SDS sheet, if available.
B. A description of the conditions under which the exposure occurred including quantitative
exposure data, if available; and includes a completed Employee Incident Report.
C. A description of the signs and symptoms of exposure that the employee is experiencing, if any.

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 Standard Operating Procedure

Physician’s written opinion: For examination or consultation required under this standard, the employer
shall obtain a written opinion form the examining physician which shall include the following:
A. Any recommendation for further medical follow-up.
B. The results of the medical examination and any associated tests.
C. A statement as to any increased risk that may exist to the employee as a result of exposure to a
hazardous chemical found in the workplace due to any medical condition which may be
revealed in the course of the examination.
D. A statement that the employee has been informed by the physician of the results of the
consultation or medical examination and any medical condition that may require further
examination or treatment or place the employee at increased risk from further exposure.
E. The written opinion shall not reveal specific findings of diagnoses unrelated to occupational
exposure.

7.0 RESPIRATOR USE

The first level of protection is to adequately utilize engineering controls and the alternative
recommended in section 4.4. This facility provides adequate engineering controls as feasible to reduce
exposure below the PEL. For any exposure situation, engineering controls should be considered or
developed to relieve the situation. Laboratory employees will not use any chemical requiring a
respirator outside of a compliant chemical fume hood.

Respirators are permitted only for employees, who have met with the requirements of 29 CFR 1910.134,
and our facility Respiratory Protection Program (GL-9074), which required prior physical exam, training
and a qualitative fit test.

Refer to Gladiator Emergency Plans for reference to any emergency situation requiring the use of
respirators shall be handled only by established procedures.

8.0 WASTE DISPOSAL

All staff will be given annual training in the safe handling and disposal of hazardous waste. When new
procedures are developed, waste is studied by project directors and lab safety employees and the
Environmental Compliance Department.

Laboratory waste will be disposed of according to GL-9091 Hazardous Materials and Waste Control Plan.

GL-9095 Medical Waste references proper handling and disposal of medical waste generated.

REVIEW AND CHANGES:

This document and all attached forms should be reviewed optimally on an annual basis, with 2 years as
the maximum review date. Review will be done by the Technical Leader, Supervisor, Manager, Medical
Director or designated person. Changes require retyping document or form and review by the Medical
Director.

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