Table of Contents Chapter 1: Introduction

Chapter 4 - Management of Chemical Fume Hoods and Other Protective Equipment

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Chapter 4 - Management of Chemical Fume Hoods and Other Protective Equipment
DSO’s – note and delete: Each PI should identify the safety equipment to be used in the laboratory, and ensure that all employees are properly trained in its use. Since no two fume hoods operate exactly alike, be sure you and your staff understand the operating principals and use safe operating procedures. Please call Environmental Health and Safety for assistance.

4.1 Fume Hoods

A. Monitoring

Fume hoods must be monitored daily by the user to ensure that air is moving into the hood. Any malfunctions must be reported immediately to Facilities Management (612-624-2900). The hood should have a continuous reading device, such as a pressure gauge, to indicate that air is moving correctly. Users of older hoods without continuous reading devices should attach a strip of tissue or yarn to the bottom of the vertical sliding sash. The user must ensure the hood and baffles are not blocked by equipment and bottles, as air velocity through the face may be decreased. DEHS staff will measure the average face velocity of each fume hood annually with a velometer or a thermoanemometer. A record of monitoring results will be made.

B. Acceptable Operating Range

The acceptable operating range for fume hoods is 80 to 150 linear feet per minute, at the designated sash opening – usually 18 inches for a vertically-sliding sash and 30 inches for a horizontally-sliding sash. If, during the annual check, a hood is operating outside of this range, DEHS staff may request that you check to ensure the baffles are adjusted properly, and that the exhaust slots are not blocked by bottles and equipment. If a fume hood is not working properly, please contact Facilities Management at 612-624-2900 to schedule a repair.

C. Maintenance

During maintenance of fume hoods, laboratories must clean out and if necessary, decontaminate the fume hood and restrict use of chemicals to ensure the safety of maintenance personnel.

4.2 Biological Safety Cabinet

When biological safety cabinets are used for Biosafety Level 2 work, including handling human cells, they must be certified annually by an outside contractor.  A list of contractors is available on the Biosafety section of the DEHS web site.  It is the responsibility of the department to schedule and pay for the contractor to perform annual certification. 

4.3 Eyewash and Shower

Eyewashes must be flushed weekly by the user. This will ensure that the eyewash is working, and that the water is clean, should emergency use become necessary. The user must post a log near the eyewash to document that it is being flushed every week. These logs are considered equipment maintenance records and therefore should be kept for 1 year. An eyewash record template is available in Appendix F. The user should also coordinate with Facilities Management to ensure that emergency showers and eyewashes are tested annually. Facilities Management will document their testing on separate tags.

4.4 Fire Extinguishers

Fire extinguishers will be checked annually by a University contractor. Please contact Facilities Management at 612-624-2900 if the fire extinguisher is out of date.

4.5 New Systems

When new ventilation systems, such as variable air volume exhaust, are installed in University facilities, specific policies for their use will be developed by DEHS and employees will be promptly trained on use of the new equipment.

4.6 Routine Inspections

Protective equipment and general laboratory conditions must be monitored periodically by the users. A laboratory self-inspection form is included in, and may be tailored for use by individual laboratories. The DSO or the Research Safety Professional may also use this form for spot-checks of the laboratories.

Chapter 5 - Employee Information and Training
5.1 Training Requirements

All laboratory researchers and their supervisors (Principal Investigators included) must be trained according to the requirements of the Laboratory Safety Standard. Colleges and non-academic departments that engage in the laboratory use of hazardous chemical, physical or biological agents are responsible for identifying such employees. The employees must be informed about their roles and responsibilities as outlined in this standard, as well as hazards associated with their work and how to work safely and mitigate those hazards.

DEHS provides web-based training modules on a number of training topics . At a minimum, new laboratory employees should complete the modules “Introduction to Laboratory Safety” and “Chemical Waste Management”. Employees that will be working with recombinant DNA or infectious agents must also take online “Bloodborne Pathogen Training”, “Biosafety in the Laboratory” and “Implementation of NIH Guidelines” training. Employees that are working with radioactive materials must take “Radiation Safety Training”.
In addition, each laboratory supervisor is responsible for ensuring that laboratory employees are provided with training about the specific hazards present in their laboratory work area, and methods to control such hazards. Such training must be provided at the time of an employee's initial assignment to a work area and prior to assignments involving new potential exposures, and must be documented. Refresher training must be provided at least annually. A lab-specific training document can be found in. This document highlights items that must be covered during lab-specific training. The document should be completed and kept on file as training documentation.

Volunteers and Visitors in the Laboratory

  • Volunteers and visitors in University of Minnesota Laboratories must complete all of the same training requirements as regular lab employees. To access training content click here and complete the ULearn account registration form.

If you have problems registering or logging in, please contact the ULearn Support Team at 612-626-0057 or

  • Volunteers and visitor’s conducting research in University laboratories must complete the Volunteers and Visitor’s Laboratory Use Agreement. If the volunteer is a minor, a parent or guardian must also sign the agreement.

  • Because laboratories may contain hazardous chemicals, a minor who is paid to work in a research laboratory must obtain an exemption from the Minnesota Child Labor Act. An overview of this law is available on the Minnesota Department of Labor & Industry website (

  • Child Labor Exemption Applications for working minors should be completed by a parent, guardian or school official and filed with the Minnesota Department of Labor and Industry. Forms are available from the Department of Labor and Industry website (

5.2 Training Content

Employee training programs will include, at a minimum, the following subjects:

  • Methods of detecting the presence of hazardous chemicals including visual observation, odor, real-time air monitoring, time-weighted air sampling, etc.

  • Basic toxicological principles including toxicity, exposure, routes of entry, acute and chronic effects, dose-response relationship, LD50, Threshold Limit Values (TLVs) and Permissible Exposure Limits (PELs), exposure time, and health hazards related to classes of chemicals

    • Prudent laboratory practices designed to reduce personal exposure and to control physical hazards (See Prudent Practices in the Laboratory: Handling and Disposal of Chemicals [National Research Council, 2011])

  • Description of available chemical information including container labels and Material Safety Data Sheets (MSDSs)

  • Emergency response information such as emergency phone numbers, fire extinguisher locations, and eyewash/shower locations

  • Applicable details of the departmental Laboratory Safety Plan including both general and laboratory-specific SOPs

  • An introduction to the University of Minnesota Hazardous Chemical Waste Management Guidebook

5.3 Training Updates

Update training is required for all laboratory researchers and supervisors / principal investigators (PI’s) at least annually. Departmental Safety Officers are responsible for coordinating and tracking update training. Often, DSOs may arrange for departmental-wide update-training sessions, focusing on results of laboratory audits, and highlighting issues that may need improvement. Videos from DEHS’s library may be borrowed to supplement these training sessions. Individual PI’s may conduct research-group-specific safety reviews to supplement or even stand in place of departmental update sessions. Documentation (paper or electronic) of all safety training must be maintained according to the requirements outlined in Chapter 10 of this Lab Safety Plan.

5.4 Access to Pertinent Safety Information

It is essential that laboratory employees have access to information on the hazards of chemicals and procedures for working safely. Supervisors must ensure that laboratory employees are informed about and have access to the following information sources:

  • The contents and requirements of the OSHA Laboratory Safety Standard

  • The content, location and availability of the departmental Laboratory Safety Plan (available within individual units or departments)

  • The Permissible Exposure Limits (PELs), action levels and other recommended exposure limits for hazardous chemicals used in the laboratory (See OSHA Annotated Table Z-1)

  • Signs and symptoms associated with exposures to hazardous chemicals used in the laboratory

  • Location and availability of Material Safety Data Sheets (MSDSs)

  • Information on chemical waste disposal and spill response (University of Minnesota Hazardous Chemical Waste Management Guidebook)

Chapter 6 - Required Approvals
DSO’s – note and delete: Certain laboratory operations, procedures or activities may warrant prior approval from a designated supervisor. Procedures involving chemicals listed in Tables 1-5 should be considered for prior approval. The PIs in the department must consider the toxicity of the chemicals used, the hazards of each procedure, and the knowledge and experience of the laboratory workers, and decide which will require pre-approval. Each PI should forward a list of the selected SOPs to the Departmental Safety Officer for reference in this section of the LSP. If none of the SOPs require prior approval, the PI should note this fact and forward a brief explanation to the DSO. In Subsection A, the DSO should summarize the department's SOPs designated for prior approval. Subsection B also requires action. The DSO must work with the PIs to develop a prior approval procedure. This procedure should be described in Subsection B.
‘High hazard’ research is that which due to the nature of the hazard, or the quantity of the material, or the potential for exposure poses higher than usual risk to the worker. Such research may require formal review and approval by a researcher’s departmental safety committee, perhaps with involvement of DEHS personnel. High hazard research could include gases or chemicals listed in Tables 1-5 of this Laboratory Safety Plan, or certain biological or physical agents. DSOs should conduct laboratory audits and consult with Principal Investigators to identify research programs which may fall into this ‘high hazard’ category.
PI’s whose research is identified as ‘high hazard’ should provide copies of their SOPs to the DSO and their department’s safety committee for review and approval. The committee should respond with any comments or requests for changes in a timely manner, and keep a written record of approvals within the department.
Chapter 7 - Medical Consultation and Examination
DSO’s – note and delete: This section requires minimal tailoring. PIs must be aware of when an employee is entitled to receive medical attention, and must ensure employees are also aware of the process that will be followed.

7.1. Employees Working With Hazardous Substances

All employees who work with hazardous substances will have an opportunity to receive medical attention, including any follow-up visits that the examining physician determines to be necessary, under the following circumstances:

  • Signs or symptoms of exposure

Whenever an employee develops signs or symptoms associated with a hazardous substance or organism to which the employee may have been exposed in the laboratory, the employee will be provided an opportunity to receive an appropriate medical examination.

  • Exposure monitoring

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 will be established for the affected employee as prescribed by the particular standard.

  • Exposure incident

Whenever an event takes place in the work area such as a spill, leak, explosion or other occurrence resulting in the likelihood of a hazardous exposure, the affected employee will be provided an opportunity for a medical consultation. Such consultation will be for the purpose of determining the need for a medical examination.

  • Physical Injury

Whenever an employee is physically hurt or injured on the job, the affected employee will be provided an opportunity for a medical consultation and/or examination. Physical injuries include but are not limited to cuts, burns, punctures and sprains.
Contact the Office of Occupational Health and Safety at 612-626-5008 whenever the need for medical consultation or examination occurs, or when there is uncertainty as to whether any of the above criteria have been met.
7.2. Medical Examinations and Consultations

In the event of a life-threatening illness or injury, dial 911 and request an ambulance. Employees with urgent, but non-life-threatening, illnesses or injuries should go to the nearest medical clinic.

Occupational Health Clinic Information

HealthPartners Occupational and Environmental Medicine is the provider for occupational health services for University employees in the twin cities. Health Partners has 3 clinic locations around the Minneapolis and St. Paul campuses.

The HealthPartners 24 hour CareLine phone service is available any time. The CareLine is staffed with registered nurses who can counsel employees on where to seek care in the event of an exposure. Call 612-339-3663 or 800-551-0859 (TTY 952-883-5474).

All medical examinations and consultations will be performed by or under the direct supervision of a licensed physician and will be provided at no cost to the employee, without loss of pay and at a reasonable time and place.

7.3. Workers' Compensation Procedures and Forms

It is very important that even minor job-related injuries or illness are reported. These statistics help the Department of Environmental Health and Safety track trends that may indicate occupational hazards that need evaluation. To report an illness or injury, go to the Workers’ Compensation website. University of Minnesota's Policy for Reporting Workers' Compensation Related Injuries is also available on the web. Both sites provide links to the forms listed below.

This policy explains the procedures and provides the necessary reporting forms. Please note that there are additional reporting requirements for any injuries or illnesses that occur while working on an IBC-approved protocol. The IBC injury report form can be found on the IBC website.
Employee Responsibilities:

  • Immediately -

    • Notify your Supervisor. Your Supervisor will assess the situation, assist with arranging proper medical care and begin the injury reporting process.

  • Promptly cooperate with your Supervisor and the Claims Administrator in the completion of all relevant documents.

Supervisor Responsibilities:

  • Immediately -

    • Assess the incident and assist the Employee in seeking appropriate medical care or necessary treatment for any work-related injury. If an injury is a potential life-threatening emergency, call 911.

    • Provide the Employee with  

      • Minnesota Workers Compensation Information Sheet

      • list of Designated Medical Providers, and 

      • Temporary Prescription Drug ID card.

  • Within 8 business hours -

    • Complete the online First Report of Injury form, or

    • Complete the paper  First Report of Injury form and fax it to the Claims Administrator.

  • Within 24 business hours -

    • Complete a Supervisor Incident Investigation Report and email or fax to the Claims Administrator at Sedgwick Claims Management Services. Fax number: 952 826 3785 or email

  • If an Employee reports an on-the-job injury which may not be compensable, the First Report of Injury form must still be submitted. Contact the Claims Administrator with any questions regarding claim compensability.

7.4. Information Provided to Physician

The employee's supervisor or department will collect and transmit the following information to the examining physician:

  • Identification of the hazardous substance(s) to which the employee may have been exposed;

  • A description of the conditions under which the exposure occurred including quantitative exposure data, if available; and

  • A description of the signs and symptoms of exposure that the employee is experiencing, if any.

7.5. Information Provided to the University of Minnesota

Supervisors should request that the examining physician provide them with a written report including the following:

  • Any recommendation for further medical follow-up;

  • The results of the medical examination and any associated tests;

  • Any medical condition which may be revealed in the course of the examination which may place the employee at increased risk as a result of exposure to a hazardous chemical found in the workplace; and

  • 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.

The written opinion will not reveal specific findings of diagnoses unrelated to occupational exposure.

Chapter 8 - Personnel
DSO’s – note and delete: Compliance with the Laboratory Safety Standard is a shared responsibility. In Chapter 1, subsection 1.2, note whether the LSP covers an entire college, a department or a specific laboratory only. Provide the name of the Departmental Safety Officer, and describe the DSOs assigned responsibilities. Appendix L includes typical responsibilities of a DSO. Some of these responsibilities may be delegated to safety committee members (if a safety committee exists), or additional duties may be added at the discretion of the department. In Subsection C, note whether or not a safety committee has been formed, and if so, what its responsibilities are.
The following individuals and groups have responsibilities for implementation of various aspects of the University of Minnesota's Laboratory Safety Plan.

  1. Research Safety Professionals

The University of Minnesota’s Research Safety Professionals are:

Anna Sitek, 612-624-8855,

Sabine Fritz, 612-625-7227,

Greg Hansen, 612-301-1158,

Jodi Ogilvie, 612-301-1214,

Kate Greenberg, 612-626-2707,

  1. College or Departmental Safety Officer

The Departmental Safety Officer for the College (or Department or Division) of __________ is __________. The specific duties of each safety officer will be determined at the college or departmental level. The duties of this DSO are included in Appendix L.

  1. College or Departmental Safety Committee

The designation of a safety committee to assist the safety officer in his/her required duties is strongly encouraged. The safety committee members are: (If there is one established)
Names of the safety committee members should be listed in this paragraph.

  1. Department of Environmental Health and Safety

The Department of Environmental Health and Safety offers assistance in a wide range of health and safety issues. Staff phone numbers are included in Appendix M. Address: W-140 Boynton. Phone: 612-626-6002.

  1. Occupational Medicine Program

All Occupational health services for university employees in the twin cities are provided by HealthPartners. There are 3 clinic locations, Riverside clinic, St. Paul clinic and Como avenue clinic. Regular appointments can be made by calling 952-883-6999. For urgent care or after hours call 952-853-8800. A 24 hour care line is also available anytime for counseling employees on where to seek care in the event of an exposure. Call 612-339-3663 or 800-551-0859.
Chapter 9 - Additional Employee Protection for Work with Particularly Hazardous Substances

DSO’s – note and delete: Like Chapter 6, this chapter also requires action. Again, the PIs in the department must consider the toxicity of the chemicals used and the hazards of each procedure, and decide whether the procedure requires the use of additional protective measures. Chemicals listed in Tables 1-5 could be considered for additional protective measures. The additional protective measures should be incorporated in the Standard Operating Procedure. Each PI should forward a list of these SOPs to the Departmental Safety Officer for reference in this section of the LSP. If none of the SOPs require additional protective measures, the PI should note this fact and forward a brief explanation to the DSO. EHS staff is available to help PIs evaluate the need for additional protective measures.
Additional employee protection will be considered for work with particularly hazardous substances. These include select carcinogens, reproductive toxins and substances that have a high degree of acute toxicity (see Appendix H - Particularly Hazardous Substances). Common chemicals designated as Particularly Hazardous Substances are listed in Tables 1-5 as the back of this document. Pp. 90-93 of the 1995 edition of Prudent Practices provides detailed recommendations for work with particularly hazardous substances. These pages may be accessed from DEHS's web site at Laboratory supervisors and principal investigators are responsible for assuring that laboratory procedures involving particularly hazardous chemicals have been evaluated for the level of employee protection required. Specific consideration will be given to the need for inclusion of the following provisions:
1. Planning;

2. Establishment of a designated area;

3. Access control

4. Special precautions such as:

  • use of containment devices such as fume hoods or glove boxes;

  • use of personal protective equipment;

  • isolation of contaminated equipment;

  • practicing good laboratory hygiene; and

  • prudent transportation of very toxic chemicals.

5. Planning for accidents and spills; and

6. Special storage and waste disposal practices.

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