Evaluation Process

Scope

All university operations and activities will be evaluated to determine:

• Compliance with policies, procedures, standards, laws, and regulations.
• The adequacy of controls employed to protect faculty, staff, students, and visitors.
• The adequacy of risk management strategies to include communication of departmental compliance expectations to employees.

Evaluation Process

Opening Conference

Building evaluations may be preceded by an opening conference coordinated by an EHS Co-Director with all affected departmental executives or their designees. The purpose of an opening conference is to:

• Overview the evaluation process and how "findings" are reported.
• Set the schedule for the evaluation.
• Determine to whom questions related to departmental operations should be addressed.
• Overview and provide information on EHS' operations and services.
• Obtain baseline information related to the departmental scope of operations and potential safety and health exposures.

Onsite Visits

EHS evaluators are assigned to various departments and/or buildings based upon the primary hazards associated with the facilities or operations and the related health and safety program, such as:

• Biological laboratories and research
• Chemical and radiological laboratories and research
• Fire and Life Safety
• Occupational Health and Safety

Facilities and operations are reviewed for compliance to established (minimum) criteria as defined in the Universal Checklist (doc | pdf). This checklist can also be used by departmental personnel to perform self-inspections as defined in the Health and Safety Policy.

Closing Conference

Upon request, or if significant issues are identified, a closing conference may be scheduled with the departmental executive and/or designee to discuss findings and expectations, and assist the department with prioritizing their response activities based upon the severity of risk, cost, and other factors.

Reporting

A formal report is provided to the individuals responsible for spaces and summary cover letters are shared with the departmental executive or designee(s) following the conclusion of onsite visits. EHS requests that a formal, written response be provided within 30 to 90 days upon receipt of the report based on the priority level of the area determined by EHS guidelines and the resulting evaluation observations.

Note: Immediately Dangerous to Life or Health (IDLH) exposures fall outside of the normal scheduled inspections and must be addressed immediately.

Re-evaluations

Re-evaluations of departments will be based upon the severity or risk and/or level of noncompliance as determined by the evaluation findings. High risk departments may be re-evaluated annually or bi-annually. Medium risk departments will be placed on a two to three year schedule. Low risk departments will be re-evaluated every four or five years.

Note: Where standards or regulations require a more frequent focused program inspection or review, such review may be conducted separate from the formal evaluation, when necessary.