Corrective Action Process
This information is to assist responsible faculty and other responsible lab members in identifying and correcting potential compliance issues and discerning potential health and safety hazards that could pose a risk to researchers, personnel, students, and the overall campus community.
It is important to understand that any deficiencies noted on the inspection report as “Required Corrective Action Items” must be corrected within the given timeframe. To ensure all required corrective action items are corrected, a corrective action process will be implemented. The corrective action process has four tiers, with ample notification and time given to all responsible parties. Failure to correct safety concerns and close corrective
actions in the inspection tool within the given time period will result in the
process moving to the next tier.
Please note that failure to close all assigned corrective
actions as part of the inspection process will impact the ability of the
faculty member to obtain Environmental Health and Safety (EHS) signatures or
approval for permits, grant certifications, or similar items that require EHS
to validate that a faculty member is in compliance with applicable state and
federal regulations. Additional follow up and re-inspections may also result from failing to correct the actions as complete.
At any time during the inspection process, the responsible faculty member or laboratory personnel may obtain assistance by reviewing the Inspections webpage and/or by contacting askEHS.
Laboratories and other research areas are regulated by the
Occupational Safety and Health Administration (OSHA) laboratory safety
standards and general industry regulations, Environmental Protection Agency
(EPA) and New York Department of Conservation (NY DEC) hazardous waste regulations,
National Fire Protection Agency (NFPA) life and fire standards, and building
codes. Inspections are conducted by EHS
of all campus research areas to assist researcher compliance with these
regulations and standards.
Corrective actions can be certified as complete, an
extension requested, or reassigned to another person using LabCliQ. Please note, for the extension or
reassignment, the Tier process remains the same.
EHS administrators can close the actions if the responsible faculty/staff member reports via email, phone, or otherwise that the actions have been completed. EHS administrators will note this correspondence in the comments section and certify the action as complete.
EHS Inspection Program Administrators will coordinate with Building coordinators and Department Safety Representatives (DSR) to schedule inspections of buildings and building complexes. Once scheduled, EHS will notify building occupants of the upcoming inspection starting date via email correspondence to the DSRs, building coordinators, and representatives.
Under special cases, EHS inspectors will coordinate with individual lab groups via a graduate lab representative to schedule specific dates and times for the inspection of their Principle Investigator’s (PI) lab spaces.
Corrective Action Process, Tier 1:
Upon completion of the laboratory or research area inspection, the Inspection Report will be sent by EHS to the faculty member, and/or lab representative responsible for the research area(s). The responsible faculty/staff will be given fourteen (14) days from the inspection date to correct any required corrective action items and to submit the Corrective Action Certification or submit an extension request or reassign the action to another person. Failure to submit the Corrective Action Certification within the given fourteen (14) day time period will result in the process moving to Tier 2.
Corrective Action Process, Tier 2:
If the Corrective Action Certification is not submitted within fourteen (14) days as noted in above, then a reminder email will be sent to the responsible faculty/staff member and carbon copy the Department Safety Representative (DSR) by an EHS administrator. The responsible faculty/staff member will be given an additional seven (7) days to correct all required corrective actions and to submit the Corrective Action Certification or submit an extension request or reassign the action. Failure to submit the Corrective Action Certification within seven (7) days will result in the process moving to Tier 3.
Corrective Action Process, Tier 3:
If the Corrective Action Certification is not submitted within seven (7) days as noted in Tier 2, then an auto-email reminder will be sent to EHS. An EHS administrator will send an email reminder to the responsible faculty/staff, the PI and carbon copy the DSR. This email reminder will state that the responsible faculty/staff member will be given an additional two (2) days to correct all required corrective actions and to submit the Corrective Action Certification or the Department Chair will be notified. If the responsible faculty/staff member does not submit the Corrective Action Certification(s) by the second day, an EHS administrator will notify the Department Chair and carbon copy the Inspection Program Administrators, PI, and DSR stating that the responsible faculty/staff member has corrective actions still open and need to be closed within an additional two (2) days to ensure escalation stops or the College Administrator (Dean) will be notified if it reaches Tier 4. Inspection Program Administrators will contact the College Safety Representative (CSR) with the above information. If necessary a meeting will be scheduled with the responsible faculty/staff member, the Department Chair, and EHS in an effort to ensure that all safety deficiencies have been corrected. A follow-up re-inspection will occur as a result of this meeting.
Corrective Action Process, Tier 4:
If the Corrective Action Certification is not submitted within two (2) days as noted in Tier 3, then an auto-email reminder will be sent to EHS. An EHS administrator will reach out directly to the CSR and Inspection Program Administrators in an effort to prevent the notification being sent to the Dean. If EHS and the CSR are unable to
work with the responsible faculty/staff member to submit the Corrective Action Certification, then an EHS administrator will submit a report to the college/unit administration (Dean) and carbon copy the PI, Department Chair, DSR and CSR indicating the status of health and safety deficiencies within each department.
At this Tier (4), the EHS administrators and EHS Inspection Program Administrators will refer the matter to the Director of Research Safety.