Administrative Requirements Inspection Criteria

Last Updated: November 4, 2026 11:01:12 AM PST

See EH&S administrative requirements criteria for laboratory inspections.

Inspection Criteria
Finding Script	Finding Description	Risk Level	Reference
If the lab is working with or in possession of biohazardous materials, is there an approved BUA?	Biological materials are stored and/or handled in the lab without approval from the IBC. The materials must remain unused in storage until approval is granted by the IBC. Work with or possession of biohazardous materials, including but not limited to, human cells, recombinant or synthetic nucleic acids, microorganisms, and viral vectors must be approved by the Institutional Biosafety Committee (IBC) before work commences. Approval is obtained by submitting a Biohazard Use Authorization (BUA) application to the IBC, receiving confirmation of committee approval, and then renewing the authorization regularly thereafter in accordance with IBC review timelines.	High	Contact the Biosafety Office (ehsbio@ucsd.edu) or see Apply for and Manage a Biohazard Use Authorization (BUA) for Laboratory Research or Clinical Trials Using Biohazardous Materials for more information.
Are all controlled substances in the lab covered by a CSUA?	A CSUA is required to use Controlled Substances for research and teaching purposes at UC San Diego. A Controlled Substance was found in the lab but PI is not enrolled in Controlled Substance Program.	High	Refer to the Controlled Substances Program for forms and detailed instructions. For more information on Controlled Substances Policy and Procedures, see Controlled Substances Use Authorization.
Has a Laboratory Self-Audit been documented since the lab's last EH&S Audit?	Laboratory self-audits are a required part of a lab's safety program. Perform an area self-audit using the "UCSD Self-Audit Form" (see Blink) three months after the EH&S audit, and quarterly thereafter for all assigned lab spaces including equipment corridors, environmental rooms, and shared lab spaces. Target the issues revealed during the audit to identify persisting problems. Maintain completed Lab Self-Audit Forms for at least three years and have available for review (e.g. set up quarterly calendar reminders to complete self-audit checklist).	Medium	Research Assistance Program Audits Laboratory Self-Audit (PDF)
Are all of the areas where the lab conducts research, stores materials, and uses equipment, listed on "My EH&S Profile"?	All laboratory or technical locations where research is conducted, materials are stored and equipment is used, need to be listed on My Research Safety — My EH&S Profile — Lab Locations list. Furthermore, BUA and CSUA locations must be listed within the respective material use applications.	Low	My Research Safety
Are the lab's larger pieces of equipment labeled with lab contact info?	Lab equipment must be labeled with emergency contact information, allowing for communication in the event of power outages or equipment failure. Label your items with PI name, Lab contact name and at least one primary email and phone number. Keep the labels posted with current information, updating as needed.	Low	N/A
Do all lab personnel have an emergency phone number listed in My EH&S Profile?	All lab members must have a current emergency/cell phone number on file so they may be contacted in case of emergency and to comply with departmental research continuity plans. Add emergency/cell phone numbers for all lab members through My Research Safety — My EH&S Profile — Lab Personnel. Click on lab personnel name to add emergency/cell phone number.	Low	My Research Safety
Are all personnel listed appropriately on the EH&S specific Use Authorizations (BUA, CSUA, RUA, LUA, MUA)?	All lab personnel handling materials or conducting research (that requires a specialty use authorization) must be registered on the corresponding use authorization.	Low	Review the Research Safety Authorizations for Principal Investigators for list and links to specialty authorizations.
Do all lab room signs meet requirements for communicating hazards present in the space?	All labs must have a Laboratory Room Sign posted outside of the entrance. This sign details the primary contacts for the lab, room hazards and responsible persons. Print a sign using My Research Safety in the Lab Locations section (look for the Room Sign PDF icon). Room signs must be printed in color and updated upon change of lab hazards, responsible personnel, their contact information, or locations. If the sign is incorrect, update the corresponding information in My Research Safety and/or contact ehsrap@ucsd.edu.	Medium	Laboratory Room Sign
Have HCPs been created, completed, and PI-approved?	Use of hazardous materials, equipment, and processes require Principal Investigators (PIs) to implement laboratory-specific standard operating procedure(s) instructing laboratory personnel on their appropriate use. EH&S has developed Hazard Control Plan (HCP) templates for each required category to facilitate the generation of these operating procedures. The HCP application, located in "My Research Safety", contains a "Chemical Evaluator" which automatically evaluates your chemical inventory and identifies which chemical Hazard Control Plans are required for your group. Similarly, the Biohazard Use Authorization (BUA) application will initiate BIO related HCPs, which may be agent-specific or grouped by hazard classification. All applicable HCPs must have personnel assigned, have effective content in the "Project Summary" and "Lab Specific Instructions" sections, and be approved by the PI to be considered complete.	Medium	Hazard Control Plan
Have all personnel been assigned to applicable HCPs, and have they reviewed/confirmed all?	In order to use hazardous materials, equipment and processes, assigned personnel must review and acknowledge their laboratory's Hazard Control Plan (HCP) located in "My Research Safety." Personnel must understand the contents and know how to access HCPs. One or more lab personnel have not been assigned to applicable HCPs, or they have not reviewed/confirmed one or more of the lab's HCPs to which they are assigned.	Medium	Hazard Control Plan
Is there complete and effective content in the Lab Specific Instructions section of the HCPs?	Cal/OSHA requires Hazard Control Plans (HCPs) to contain laboratory or process specific information. Review the lab's HCPs to ensure that this instructional information is included. This section is where the lab must communicate specific safety requirements. Provide detailed instructions on how to safely work with the chemicals, biological materials, equipment, or processes by considering the actual details of the lab's research protocol and any other aspects of the specific nature of your research. Consider the following when populating this field: quantities, concentrations, conditions of use, unusual or dangerous characteristics, quenching procedures, genetic modifications, aerosol-generating procedures, PI restrictions, where it will be used, scale-up restrictions and physical process highlights such as heating, pressure, cooling, etc. It is the PI's responsibility to provide sufficient instructions in each HCP to ensure safe research activity within their lab. Consult with EH&S subject matter expert for research-specific details if needed.	Low	Hazard Control Plan
Do all lab members have a lab coat and eye protection readily available and documented in the LHAT?	Eye protection and properly fitted laboratory coats must be issued to lab personnel when working with or adjacent to hazardous material use areas. Issuance of this personal protective equipment (PPE) must be documented in the Laboratory Hazard Assessment Tool (LHAT) and be readily available for use.	Medium	Personal Protective Equipment Regulations and Policies UC Laboratory Safety Policies PPE for Researchers
Is the lab's LHAT completed and approved with a review documented within the last 3 years?	Laboratories are responsible for assessing the appropriate level of personal protective equipment for the activities they conduct. The EH&S Laboratory Hazard Assessment Tool (LHAT) must be completed to document this assessment. Update each LHAT as hazards and personnel change, and at least once every three years, irrespective of changes to hazards or personnel.	Medium	Complete a Laboratory Assessment for PPE PPE Requirements for Research Employees
Have all lab members reviewed and acknowledged the LHAT?	All laboratory personnel are required to review and acknowledge their assigned Laboratory Hazard Assessment Tool(s) [LHAT(s)] to ensure their familiarity with the specific personal protective equipment (PPE) requirements for activities performed in the lab. Laboratory personnel were either not assigned to the LHAT and/or have not read/acknowledged the LHAT. Assign lab personnel to the applicable LHAT(s) and direct them to read and acknowledge assigned LHAT(s).	Low	PPE Requirements for Research Employees
Do all lab members have access to the LHAT-required shared PPE, knowledge of the location, and is the storage location documented?	Shared personal protective equipment (PPE) identified by the Laboratory Hazard Assessment Tool (LHAT) must be made available to all personnel conducting that activity and have a storage location documented. All members must know where to find this required shared PPE. Update the location of the shared PPE in LHAT and ensure awareness of storage location for ease of use.	Low	PPE for Researchers
Do all lab personnel know the building evacuation route(s) and designated assembly area(s)?	Lab personnel must know and frequently review evacuation route(s) and designated assembly area(s). Review the building's posted Emergency Exit Plans located near every stairwell/elevator. Additional building evacuation information can be found in the "Building Evacuation Procedures" and "Emergency Preparedness" Blink pages and in the red Emergency Preparedness Procedures Guide posted in the lab.	Low	Building Evacuation Procedures Emergency Guide Emergency Preparedness
Do all lab personnel know how to access Safety Data Sheets for chemicals they use?	Safety Data Sheets (SDSs) and other chemical and biohazard information can be accessed from any UC San Diego internet-connected computer through a link on the "My Research Safety" page and on Blink. Always review the SDS before starting work with a new chemical or hazardous substance.	Low	Safety Data Sheet Sources
Do all lab personnel know the location of the nearest eye wash/safety shower?	An eye wash and emergency shower must be available within 10 seconds of unobstructed travel from where hazardous materials are used, and all lab members must be aware of its location. Laboratory emergency procedures must be reviewed and understood by laboratory personnel.	Low	Eye Wash and Emergency Shower Guidelines
Have all lab personnel been trained in hazardous materials spill response procedures?	Lab personnel must understand how to respond to a hazardous material spill, including how to reach EH&S and the campus police for assistance with larger or higher hazard spills.	Low	How to Handle Chemical Spills in Laboratories
Are all lab personnel familiar with, and know how to access, the Laboratory Safety Manual?	The Laboratory Safety Manual (which includes the Chemical Hygiene Plan) is a comprehensive online resource of UC San Diego laboratory safety policies and procedures. Cal/OSHA mandates that all employees be informed of the contents, know the location, and have ready access to employer's Laboratory Safety Manual/Chemical Hygiene Plan.	Low	Laboratory Safety Manual
Are all lab personnel familiar with accident and injury reporting procedures?	UC San Diego requires that any work-related injury, illness, or hazardous material exposure be reported immediately. Campus funded employees, students, volunteers or visitors must notify their supervisor and complete an incident report.	Low	See Report a Work-Related Injury, Illness, or Hazardous Material Exposure for reporting instructions, timelines, definitions, and medical treatment guidance. Personal Injury
Have all members working with BBP completed the annual required training?	Bloodborne Pathogens (BBP) training is required on an annual basis for all researchers working with human or primate blood, blood products, body fluids, tissue or cell lines, and infections agents such as HIV, HepB, and HepC. Initial and refresher BBP training is provided online at UC Learning Center. Refer to the "Bloodborne Pathogens Program" page on Blink for additional details.	Medium	Bloodborne Pathogens Training and Annual Refresher Bloodborne Pathogens Program
Have all members working with recombinant or synthetic nucleic acids completed the required training?	Recombinant and Synthetic Nucleic Acids training is a one-time requirement for personnel who are assigned to use recombinant and synthetic nucleic acids in Risk Group 2 (or higher), viral vectors or organisms. Training is provided online at UC Learning Center.	Medium	See Recombinant and Synthetic Nucleic Acids training details on the "Biosafety Training."
Have all members working with aerosol transmissible disease pathogens completed the annually required training?	Aerosol Transmissible Disease Pathogens (ATD) training is required on an annual basis for personnel assigned to use any of the pathogens identified by Cal-OSHA, in Title 8, Section 5199, Appendix D. This includes pathogens, such as Salmonella, Shigella, and Epstein-Barr virus. ATD training is provided online at UC Learning Center.	Medium	Aerosol Transmissible Disease Pathogens
Are all lab members on the MRS PI Profile Lab Personnel List and do they all have a completed New Worker Checklist uploaded?	Maintain an accurate list of personnel in the My Research Safety — PI Profile — Lab Personnel list. Additionally, site specific training must be completed for each person on the list to demonstrate all personnel are aware and knowledgeable of all safety equipment and procedures for the facility. A "UC San Diego New Laboratory Worker Checklist" or "New Tech Worker Checklist" is provided and required to facilitate this documentation. Upload completed New Worker Checklists to EH&S Training Analytics page.	Medium	Laboratory Safety Training EH&S Forms New Laboratory Technical Worker Checklist (PDF)
If a Tech Lab, are all members on the My Research Safety- PI Profile- Lab Personnel list in compliance with the IIPP and Shop/Studio Safety training requirements?	Safety training documentation was incomplete or expired. All Tech Lab personnel must complete the following: 1) Injury and Illness Prevention Program (IIPP) Training prior to beginning work (once upon start of hire), 2) Annual Shop & Studio Environmental Compliance & Hazards Training prior to beginning work and annually thereafter (every 365 days).	Medium	All trainings can be found online with direct links to UC Learning Center through Technical Research Safety Training Requirements.
Are all lab members on the My Research Safety-PI Profile-Lab Personnel list currently in compliance with the Annual Laboratory Hazards and UC Lab Safety Fundamentals training requirements?	Laboratory safety training documentation was incomplete or expired. All laboratory personnel must complete the following: 1) UC Laboratory Safety Fundamentals prior to beginning work, and the Laboratory Safety Refresher every three years thereafter, 2) Annual Laboratory Hazards Training prior to beginning work and annually thereafter.	Medium	All trainings can be found online with direct links to the UC Learning Center from our Laboratory Safety Training.

Questions? Contact the EH&S Research Assistance Program.