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Administrative (Non-Clinical) Policy
UWHC only (Hospital Administrative-entity wide) UWMF only (entity wide)
UWHC Departmental (indicate name) UWMF Departmental (indicate name)
UWHC and UWMF (shared)
Policy Title: Chemical Hazard Communication Program
Policy Number: 12.37
Effective Date: July 1, 2015
Chapter: Environmental Safety
To develop a plan for employees of the University of Wisconsin Hospital and Clinics that communicates
the chemical hazards in their work place. This program is to include identification of hazards, gathering of
information on the hazards, training of employees on correct practices, protective measures, monitoring,
and evaluation of the program.
It is UWHC policy to manage hazardous materials from the point of requisition to the point of disposal in
a manner that will protect patients, visitors, and the environment from any adverse effects; and to reduce
occupational illness and health problems through education, awareness, standard operating procedures,
and by reducing exposure to levels as low as reasonably achievable.
A. The Department Manager is responsible for:
1. Conducting an annual inventory of hazardous chemicals in the work place identifying the
chemical/product, location, amount, and use.
2. Sending the inventory list to the Department of Safety. Current list can be requested
from the Safety Department or found on MSDSOnline.
3. Reviewing labels of all chemical containers upon receipt and annually to ensure that the
contents are accurately identified. Provide accurate labels when necessary.
4. Obtaining the necessary training for managers and supervisors to be able to adequately
train employees with regard to chemical safety. Necessary training requirements may be
obtained from the UWHC Department of Safety or the Director, Life Safety.
5. Developing a training program that includes all employees of the department and all new
employees prior to their first work assignment which includes;
a. Awareness training of chemicals used in their work area and all chemicals in the
department inventory, or those that have been ordered or recently
delivered. Training on how to access, identify and understand Safety Data Sheets,
or other chemical reference guides and /or materials. Appropriate training can be
found on the Safety Department website.
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b. Hazardous properties of the chemicals inventoried to include information on
incompatible chemicals that are inventoried, what to avoid, and how to react if
spills occur or if chemicals mix.
c. Protective measures those employees must take to ensure their safety including
Personal Protective Equipment (PPE) use, care and maintenance.
d. Emergency and immediate aid procedures if exposed. Who to contact and where
to proceed if exposed or injured. (i.e., Employee Health Services during their
open hours M-F, 7am-4:30pm, or the UWHC Emergency Department when
Employee Health Service is closed and at any time that emergency treatment is
e. Safe handling of chemicals that are part of the employees work responsibilities to
include a protocol review by the supervisor or lead worker.
f. How to reduce or prevent exposure to hazardous chemicals through the use of
control procedures, work practices, and personal protective equipment.
g. How to clean up spills and dispose of chemicals in accordance with U.W. Safety
Department guidelines, label requirements and Safety Data Sheet.
h. Use of Workers' Accident and Illness Report form and Patient Safety Net form
(PSN). (Refer to on line versions that are located on U Connect).
i. Reporting to supervisor, lead worker, or Director, Life Safety all spills,
exposures, or injuries. Must submit a PSN on spills, incidents or near misses.
j. Document training of all employees and conduct an annual review to ensure that
all employees have participated in training program.
k. It is necessary for work area supervisors to provide additional employee training
concerning workplace hazards when:
i. New Materials or processes are introduced into the workplace
ii. Process or equipment changes are made that could cause new or
increased employee exposure
iii. Procedures or work practices are introduced or changed, which could
cause changes in the employees exposure.
iv. Employees are transferred from one work area to another where different
hazards are present.
B. The Director, Life Safety is responsible for:
1. Developing, updating and maintaining training programs and information as required by
state, federal and local requirements.
2. Collection of chemical inventory lists from departments.
3. Communication and follow-up on all hazardous chemical spills and exposures.
WI Adm Code, Department of Commerce, Chapter COMM 32, Public Employee Safety and Health, July
Wisconsin Employee Right to Know Law
U.W. Safety Department Laboratory Waste Disposal and Safety Guide
Occupational Safety and Health Administration (OSHA) 29 CFR 1910. 132-137
NIOSH Guide to Chemical Hazards
NFPA 99, NFPA 101
Hospital Administrative policy 12.25-Hazardous Materials and Gases/Radioactive Materials
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Sr. Management Sponsor: VP, Facilities & Support Services
Author: Director, Life Safety
Review/Approval Committee(s): Environment of Care Safety Committee, Administrative Policy &
President & CEO
Previous revision: 072012
Next revision: 072018