Environmental, Health, Safety (EHS) and Risk Management Policy

Introduction and Purpose

The purpose of this policy is to ensure that Montana State University meets its mission in compliance with applicable Federal, State and Local Environmental Health and Safety (EHS) regulations, laws, rules and standards.

MSU Statement of Commitment

Montana State University - Bozeman (MSU) is committed to maintaining a safe campus environment for faculty, staff, students, and visitors that will not adversely affect the environment. MSU values the safety of our community such that no one will be required to perform any task that is determined to be an unacceptable risk.

MSU Statement of Accountability

To maintain a safe campus environment, all campus units will provide facilities, equipment and training that meet all Federal, State and Local Environmental Health and Safety (EHS) laws, rules, and regulations and will promulgate appropriate policies, standards and procedures to ensure compliance with the University's EHS Programs .

The ultimate responsibility for establishing and maintaining the EHS Programs at MSU rests with the President and Vice Presidents of the University. The guidelines found in the EHS Programs are reviewed and approved by topical committees (EHS Committee, Institutional Biosafety Committee, Radiation Safety Committee, Institutional Animal Care and Use Committee) with recommendations from MSU Safety and Risk Management (SRM) and the Office of Research Compliance (ORC) as warranted.

The primary responsibility for the environmental health and safety of the workplace belongs to each University employee. However, employees functioning in a supervisory role have a heightened responsibility to ensure that safe conditions, procedures, practices, and training are provided within their areas of managerial oversight. Members of the campus community shall cooperate fully with all aspects of the EHS Policy and Programs. Failure to comply with established EHS rules, regulations, and procedures may lead to University disciplinary action.

Note: A list of abbreviations is included at the end of this policy document.

100.00 Administering Agency and Authority

The EHS Programs provide specific written programs, procedures, hazard mitigation activities, training and documentation which are required by various laws, regulations and standards including, but not limited to, the following:

1. Administrative Rules of Montana (ARM): ARM 24.30.102(5) (extension incorporates Occupational Safety &Health Administration (OSHA) General Industry Citations from Title 29, 1910 or 1926)
2. National Fire Code (NFC)
3. National Fire Protection Association (NFPA) Standards and Regulations
4. Nuclear Regulatory Commission (NRC) Requirements set forth in Title 40, CFR
5. Resource Conservation and Recovery Act
6. Montana Department of Environmental Quality (DEQ)
7. Higher Education Opportunity Act, public law
8. Montana Board of Regents (BOR) Policies
9. Montana Safety Culture Act, 39-71-1501 to 1508, M.C.A.
10. Environmental Protection Agency (EPA)
11. Department of Homeland Security (DHS)
12. Montana Code Annotated (MCA)
13. Biosafety in Microbiological and Biomedical Laboratories (CDC)
14. Recombinant and/or Synthetic Nucleic Acid Guidelines (NIH)
15. Select Agent and Toxins (USDA/CDC)
16. Animal Welfare Act and Animal Welfare Regulations (USDA)
17. The Guide for the Care and Use of Laboratory Animals (NIH)

200.00 Scope

The EHS Policy applies to all MSU employees.

300.00 EHS Programs

EHS Programs are established to support this policy and to assist management in identifying, eliminating, preventing and mitigating workplace hazards. EHS Programs are developed with subject matter expert input, and are intended to:

1. Address and communicate compliance mandates;
2. Outline training requirements commensurate with job responsibilities and hazards;
3. Communicate safe operating parameters.

400.00 Responsibilities

400.10 University Administration

University President and Vice Presidents are ultimately responsible for establishing and maintaining effective EHS Policies and Programs for MSU.

400.20 Safety and Risk Management Department

SRM is responsible for:

1. Providing leadership to develop and implement EHS Programs under its jurisdiction and having them reviewed by the MSU EHS Committee.
2. Ensuring that EHS policies, written programs, and guidelines under its jurisdiction are communicated, implemented and evaluated for compliance and effectiveness.
3. Reviewing and incorporating program changes from new and/or revised EHS codes, rules, and standards adopted, passed or enacted by applicable governmental or regulatory authorities.
4. Investigating identified hazards and recommending actions to correct EHS deficiencies.
5. Providing technical resources, staff support, advice, and consultation to University leadership, Safety Coordinators (SC), managers and supervisors concerning EHS issues under its jurisdiction.
6. Assisting in maintaining centralized EHS records, inspection reports, and compliance reports.
7. Acting as the University liaison with governmental and regulatory agencies regarding EHS programs under its jurisdiction.
8. Working with management and unit leaders to stop any University related activity which presents an unreasonable health or safety risk to University employees, students or visitors, and to re-evaluate, and to continue after appropriate controls are in place.

400.30 Office of Research Compliance

ORC is responsible for:

1. Providing leadership to develop and implement EHS Programs under its jurisdiction and having them reviewed by the appropriate topical committee (Biosafety, Radiation Safety, Animal Care and Use).
2. Ensuring that EHS policies, written programs, and guidelines under its jurisdiction are communicated, implemented and evaluated for compliance and effectiveness.
3. Reviewing and incorporating program changes from new and/or revised EHS codes, rules, and standards adopted, passed or enacted by applicable governmental or regulatory authorities.
4. Investigating identified hazards and recommending actions to correct EHS deficiencies.
5. Providing technical resources, staff support, advice, and consultation to University leadership, Safety Coordinators (SC), managers and supervisors concerning EHS issues under its jurisdiction.
6. Assisting in maintaining centralized EHS records, inspection reports, and compliance reports.
7. Acting as the University liaison with governmental and regulatory agencies regarding EHS programs under its jurisdiction.
8. Working with management and unit leaders to stop any University related activity which presents an unreasonable health or safety risk to University employees, students or visitors, and to re-evaluate, and to continue after appropriate controls are in place.

400.40 Deans, Directors, and Department Heads

Deans, Directors, and Department Heads are responsible for:

1. Providing a safe and healthful environment in those areas and for those employees, students and others for whom they have supervisory or administrative responsibility, incorporating safety and health as an integral part of their activities.
2. Ensuring compliance with EHS Programs, policies, procedures and guidelines in their work units or areas as specified in the EHS Programs .
3. Ensuring corrective action is taken to remedy any health, safety, or compliance deficiencies identified in their areas of responsibility.
4. Appointing sufficient SCs to perform the responsibilities provided in Section 400.60 below to cover all of their areas of responsibility.
5. Complying with SRM and/or ORC requests to cease any University related activity which presents a compliance issue or an unreasonable health or safety risk to University employees, students or visitors and to re-evaluate, and to continue after appropriate controls are in place.

400.50 Managers, Supervisors, Faculty, and Principal Investigators

Managers, Supervisors, Faculty and Principal Investigators (PI) are responsible for:

1. Ensuring effective implementation of and compliance with EHS Programs, policies, procedures and guidelines as they relate to their operations.
2. Ensuring that all employees and students receive the appropriate EHS training as well as instruction regarding general safe work practices and instructions specific to their job duties. Such education and training shall take place prior to assignment to potentially hazardous activities.
3. Ensuring documentation of all EHS training of employees and students in their areas of responsibility is maintained.
4. Developing and maintaining an inventory of hazardous materials present in all work areas within the department. (SRM and ORC can provide assistance if requested.)
5. Posting appropriate safety notices and/or procedures in conspicuous locations.
6. Developing methods, as appropriate, to inform employees of outside contractors and/or University maintenance personnel working in areas under their supervision of the hazards to which those employees may be exposed.
7. Reviewing accident and injury reports for their area(s).
8. Promptly notifying SRM and ORC when they become aware of a violation of any University, State or Federal environmental health or occupational safety rule or regulation.
9. Seek assistance from SRM and ORC if a safety or environmental problem exists that cannot be handled with available resources.
10. Complying with SRM and/or ORC requests to cease any University related activity which presents a compliance issue or an unreasonable health or safety risk to University employees, students or visitors and to re-evaluate, and to continue after appropriate controls are in place.

400.60 Safety Coordinators

SCs are appointed by Deans, Directors, or Department Heads and are critical to the effective implementation of the MSU EHS Programs, ensuring MSU's compliance, and developing a culture of safety.

SCs are responsible for:

1. Coordinating with SRM and ORC and campus stakeholders in building a culture of safety.
2. Assisting the Dean, Director or Department Head in the implementation of required EHS Programs.
3. Assisting the Dean, Director or Department Head in the identification and implementation of required training programs for employees.
4. Coordinating EHS activities, including coordinating EHS training for their areas.
5. Assisting SRM and ORC in conducting periodic inventories and inspections.
6. Preparing written reports, recordkeeping, and recommendations as needed to assist in compliance with EHS Programs .
7. Providing assistance to correct identified deficiencies.
8. Coordinating EHS issues with appropriate building supervisors.

400.70 Employees

All MSU employees and students are empowered to stop work immediately if unsafe conditions exist and are responsible for:

1. Exercising sound judgment at all times to avoid potential hazards that may exist or be created in the work environment.
2. Reading and complying with EHS policies, procedures and guidelines governing their activities.
3. Promptly reporting unsafe conditions, environmental hazards as well as injuries and illnesses to the responsible supervisor or program director.
4. Successfully completing all required EHS training sessions required by work tasks or location.
5. Communicating with their supervisors, SRM or ORC when there is a concern about an unknown or potentially hazardous situation.
6. Conducting themselves in a manner which promotes safety and avoids unsafe or unhealthful conditions.

500.00 Safety Committees

500.10 EHS Committee

The EHS Committee has responsibility to represent all of MSU-Bozeman regarding health and safety issues. The University is cognizant of its responsibility to provide an environment conducive to the health and safety of all employees, students, visitors and neighbors. In order to establish effective, uniform policies and programs in this area, the University EHS Committee has been established to advise MSU senior leadership.

500.11 Purpose

The purpose of the University's EHS Committee is to recognize, evaluate, and recommend controls of university environmental factors which might impair health and safety. The EHS Committee guides and supports the work of SRM and ORC toward these goals and strives to develop a positive attitude toward safety in the faculty, staff, and students.

500.12 Responsibilities

The University EHS Committee responsibilities include:

1. Reviewing and/or recommending the adoption of EHS Policies related to Occupational Health and Safety such as chemical safety, hazardous waste, noise, confined space, fall protection, ergonomics, vehicle safety, and fire safety.
2. Reviewing occupational injury and illness records to identify and communicate lessons learned and to prevent recurrence.
3. Advising the University's senior leadership on the status of EHS Programs and their needs.
4. Communicating EHS information to University departments.

500.20 Relationship of EHS Committee to Office of Research Compliance

The Office of Research Compliance (ORC) oversees focused EHS Committees including the Institutional Animal Care and Use, Biosafety, Institutional Biosafety, and Radiation Safety Committees. ORC Programs have developed appropriate polices, standards and procedures to ensure a safe and compliant environment in these areas of research and study.

500.30 Safety Committees at the College, Department, Program, and/or Work Unit Level

Deans, Directors, Department Heads, Managers and Supervisors may establish safety committees to function at the appropriate area of responsibility. Should a Dean, Director, Department Head, Manager or Supervisor elect to utilize a safety committee within their operational level of the MSU organization, the duties and responsibilities of the appointed safety committee should include responsibilities such as the following:

1. Periodic review of accidents, injuries, damage and hazardous conditions reports within the corresponding operational level of organization.
2. Implement appropriate occupational health and safety improvements.

600.00 Compliance Guidelines

All employees shall adhere to safe and healthful work practices as defined by law and established University and departmental environmental health and safety policies, programs, and guidelines. Failure to do so may result in disciplinary action. Disregarding or failing to comply with EHS laws, regulations, policies or procedures may result in disciplinary action.

700.00 Safety Communications

700.10 Departmental Safety Communications

SCs will determine the need for and will periodically communicate (e.g., meetings, email, newsletters, etc…) health and safety concerns and topics. These communications should be provided such that all impacted employees receive the information. SCs will keep documentation of which employees received the information and the topics communicated. Health and Safety communications minutes will be provided to SRM or ORC upon request.

700.20 Employee Safety Training

Departments will ensure that all employees receive specific training relating to their employee duties and responsibilities either on a periodic basis or prior to assignment on a new job or when work assignments change as provided in Section 1100 of this policy.

700.30 Student Safety Training

Faculty and staff are responsible for providing specific training programs (e.g., lab safety, art safety, shop safety, etc.) applicable to the student(s) prior to any academic or research activities. Students who are employees shall be considered employees for purposes of the specific job or work assignments relating to their employment. Managers, Faculty, Supervisors and PI are responsible to see that the records of trainings will be maintained per section 1100.60 of this policy.

700.40 Environmental Health and Safety Training Resources

SRM and ORC provide several different types of resources regarding EHS training as provided in Section 1100 of this policy.

700.50 Safety Suggestions

Any environmental, health or safety concerns can be referred to SRM or ORC.

700.60 MSU President's Policy Statement

The MSU President, or designee, will periodically issue an EHS Policy statement which informs the University community that health and safety is a priority issue among MSU's executive level administrators. The policy statement will urge all faculty and staff to actively participate in the MSU EHS Programs for the common good of the entire campus community.

800.00 Hazard Control and Inspections

Regular health and safety inspections are essential in order to create a culture of safety. A program of regular environmental health and safety inspections conducted at various levels throughout the MSU organization will help reduce the risk of injury and illness for faculty, staff, students and the public.

Safety and Risk Management will work in conjunction with the Vice President of Research and Economic Development to ensure laboratory safety when necessary.

800.10 Hazard Control Procedures

Many hazards can be prevented from occurring through documented self-inspections. An effective hazard control system will identify potential hazards that exist or develop in the workplace, will determine how to correct hazards, and will take steps to prevent recurrence of hazards.

Upon completion of scheduled or unscheduled inspections, all findings will be prepared in writing and submitted to respective department heads and SRM or ORC, depending on the nature of the inspection. Corrective action or a suitable timetable for elimination of a hazard is the responsibility of the supervisor.

Once identified, hazards will be evaluated with regard to their severity potential. As the severity potential increases, the more urgent it is to correct the potential hazard, or to ensure that the hazard is removed from the workplace until such time as it can be corrected.

800.20 Scheduled Workplace Inspections

1. SRM and ORC will schedule and periodically conduct inspections of various work environments. The purpose of these inspections will be to assist departments in identifying their compliance deficiencies as identified in various EHS regulations, codes and policies. Written review of identified compliance deficiencies will be provided. The departments are responsible for initiating actions to correct reported compliance deficiencies.

800.30 Unscheduled Workplace Inspections

1. Departments will ensure a safety review is performed whenever they become aware of additional substantial safety hazards that are introduced into the work environment.
2. SRM and ORC may conduct periodic unscheduled inspections of any workplace to help ensure the maintenance of a safe and healthy work environment. The purpose of these inspections will be to identify deficiencies, improve compliance, and aid in the creation of a safe and healthy work environment. Each department and/or work area inspected will receive a written review of identified deficiencies, concerns and recommendations. MSU departments are responsible for initiating actions to correct reported compliance deficiencies.

800.40 Regulatory Agency Workplace Inspections

All work environments at MSU may be subject to periodic EHS and code compliance inspections conducted by various governmental and regulatory agency. In many instances, departments will have advance notice of the intended inspection; however in some cases regulatory personnel may conduct unannounced inspections. Departments are instructed to take the following steps when approached by a regulatory representative desiring to conduct an unannounced inspection of an MSU workplace:

1. Contact the following departments/individuals:
1. Department Head
2. Safety and Risk Management and the Office of Research Compliance

It is recommended to have staff from SRM or ORC accompany the regulatory representative on the inspections within their jurisdictions.

900.00 Accident Reporting

900.10 Employee's Responsibilities

All employees are required to report to their immediate supervisor an on the job injury or what they believe to be an on the job injury as soon as reasonably possible after the injury occurs. All occupational diseases, or what they believe to be an on the job disease, should be reported to the immediate supervisor as soon as the employee has reason to believe the illness is work related. Current definitions as defined by Montana Code Annotated. The supervisor will help the employee complete a First Report of Injury form.

Reporting hazardous conditions, policy or program violations and/or workplace hazards is encouraged and can be done without fear of reprisal by contacting SRM and/or ORC by e-mail, phone or safety concern form or by using MSU's on-line compliance reporting tool, which allows anonymity.

900.20 Supervisor's Responsibilities

When an occupational injury or illness is reported to a supervisor, the supervisor and employee will submit a First Report of Injury form and ensure that other reporting requirements specified in SRM occupational injury reporting instructions are met.

1000.00 Written Program Requirements

In addition to this EHS Policy, some function-specific written programs are required by occupational health and safety rules, standards, and applicable policies to document responsible persons, legal requirements, and other useful information for departments, supervisors and employees.

1000.10 EHS Required Written Programs and Procedures

Specific written program or procedure requirements are dependent upon the work environment, job tasks, duties and/or materials, tools and equipment utilized.

Administrators, supervisors and managers have the responsibility to conduct an assessment to identify the written programs required for work environments and activities under their supervision. Assistance is available through SRM and ORC.

1000.20 EHS Recommended Written Programs and Procedures

EHS Recommended Written Programs and procedures are those not required by code, statute, policy and/or regulation but may benefit an employee or group of employees by helping to clarify safety responsibilities and document safe work practices. Although not required, these recommended written programs and procedures may provide a better way to manage the root cause of documented occurrences of occupational injuries and illnesses or loss. MSU administrators, managers and supervisors are encouraged to identify the EHS Recommended Written Programs and procedures that will benefit the employees under their supervision.

1100.00 Employee Safety Training Requirements

Effective dissemination of safety information is essential to employee safety and is required by occupational health and safety rules, standards, and applicable policies. It is necessary to provide training for employees concerning general work practices and emergency procedures as well as specific instruction with respect to hazards unique to each employee's job assignment.

1100.10 EHS Required Training Programs

The required trainings applicable to various MSU employees are listed on the SRM and ORC web sites and will be regularly maintained and updated. The specific training is dependent upon the work environment, job tasks, duties and/or materials, tools and equipment utilized in the job or profession. When training is required by law or policy, training shall take place prior to initiating the work assignment.

Required training is a facet of an employees' position with MSU and shall be considered paid time within their normal working hours. Administrators, supervisors and managers have the responsibility to conduct an assessment to identify the training programs required for each employee under their supervision. SRM and ORC are available for assistance in identifying the required programs for employees.

1100.20 EHS Recommended Training Programs

EHS Recommended Training Programs are designed to help reduce the risk of occupational accident or illness and prevent unnecessary property damage and loss to a department or program. Although not legally required, these recommended trainings may provide an enhancement in managing the risks of occupational injuries and illnesses or loss. MSU administrators, managers and supervisors are encouraged to identify the EHS Recommended Training Programs that will benefit the employees under their supervision.

1100.30 New Employee Safety Training

All supervisors will ensure that newly hired employees attend all required trainings at the earliest practical opportunity after hire. When training is required by law or policy, training shall take place prior to initiating the work assignment.

1100.40 Transferred Employee Training

All supervisors will ensure that existing MSU employees receive required general safety training at the earliest practical opportunity and required specific training prior to working new job assignments, prior to initiating the work assignment.

1100.50 Changes in Work Environment

Supervisors will ensure that employees receive required trainings whenever new substances, processes, procedures or equipment are introduced to the workplace which represent a new hazard, or whenever the supervisor receives notification of a new or previously unrecognized hazard.

1100.60 Training Documentation

Training records will include the topics, participants and dates of completion or attendance. MSU must ensure that all records of employee safety training are created and maintained either by SRM, ORC, departments, or if established, a central training records repository.

1200.00 Environmental and Occupational Recordkeeping

Records for occupational injuries and illnesses, medical surveillance, exposure monitoring, inspections, as well as other activities and incidents relevant to EHS will be maintained per governing standards, regulations, or best practices.

1200.10 Occupational Injuries and Illnesses

All occupational injuries and illnesses shall be reported as per Section 900 of the EHS Policy and Personnel Policy and Procedures Manual . SRM will record and report all occupational injuries and illnesses as required by State and Federal laws. Information will be kept on file and will be made available for review upon lawful request.

SRM will annually publish a summary of occupational injuries and illnesses as required by law. The summary will include occupational accidents and illnesses occurring in the previous calendar year. The annual summary will be posted in conspicuous places throughout campus traditionally used for posting employee and employment related information.

1200.20 Employee Exposure Records

Each employee exposure record will be preserved and maintained for the respective employee's duration of employment plus (30) thirty years. Such records include, but are not limited to: workplace monitoring or measuring of a toxic substance or harmful physical agent; and where applicable biological monitoring results which directly assess the absorption of a toxic substance or harmful physical agent by body systems. It is the responsibility of departments using any regulated carcinogens to comply with any additional record keeping requirements under Montana Department of Labor and Industry (DLI) rules.

1200.30 Employee Occupational Medical Records

Occupational medical records for employees will be preserved and maintained for at least the duration of employment plus (30) thirty years. Such records include medical and employment questionnaires or histories; the results of medical exams and lab tests; medical opinions, diagnoses, progress notes, and recommendations; first aid records; descriptions of treatments and prescriptions; and employee occupational medical complaints. All such employee occupational medical records shall be kept strictly confidential and will only be used for the purposes identified in section 1300 below.

1200.40 Documentation of Activities

Essential records, including those legally required for workers' compensation insurance, insurance audits and regulatory inspection shall be maintained as required by law. The departments will keep records of steps taken to establish and maintain programs which must include the following:

1. Records of scheduled and periodic inspections to identify unsafe conditions and work practices. The documentation includes the name of the person(s) conducting the inspection, the unsafe conditions and work practices identified, and the corrective action(s) taken with copies forwarded to SRM. These records will be maintained for the life of the institution.
2. Documentation of environmental health and safety training for each employee. Specifically, employee name or other identifier, training dates, type(s) of training and the name of the training provider will be included. Training records will be maintained for the life of the institution.

1300.00 Access to Exposure and Medical Records

MSU recognizes that employees, their designated representatives, authorized representatives of the DLI - Safety Bureau, and other State or Federal officials as authorized by law have a right of access to relevant exposure and medical records. Such access is necessary to yield both direct and indirect improvements in the detection, treatment and prevention of occupational disease. Upon access request, the University shall assure that access is provided in a reasonable time, place and manner.

Appendix I: Definitions

Department: Working units (i.e. institute, academic department, center, administrative departments, etc.)

Acronyms

• ARM: Administrative Rules of Montana
• BOR: Montana University System Board of Regents
• DEQ: Montana Department of Environmental Quality
• DHS: Department of Homeland Security
• DLI: Montana Department of Labor and Industry
• EHS: Environmental Health and Safety
• EPA: Environmental Protection Agency
• IACUC: MSU Institutional Animal Care and Use Committee
• IBC: MSU Institutional Biosafety Committee
• IRB: MSU Institutional Review Board
• MCA: Montana Code Annotated
• MSU: Montana State University- Bozeman
• NFC: National Fire Codes
• NFPA: National Fire Protection Association
• NRC: Nuclear Regulatory Commission
• OSHA: Occupational Safety and Health Administration
• ORC: Office of Research Compliance
• PI: Principal Investigator
• RSC: MSU Radiation Safety Committee
• SC: Safety Coordinator
• SRM: MSU Safety and Risk Management Department