CoS Inspections and Audits

Lab/Shop Safety Inspections

  • Inspection Checklists: University Environmental Health & Safety maintains the lab and shop safety inspection checklists. The checklists are available on the SJSU Illness & Injury Prevention Program website. 
  • Teaching Lab/Shop Inspections: Departmental staff are responsible for teaching lab/shop safety inspection responses. Course instructors' involvement in safety inspections is not common but this may be incorporated into instructor responsibilities for some departments.
  • Inspection Frequency: The College Safety Team conducts lab/shop safety inspections twice a year. Lab/shop supervisors can request to schedule the inspection for a convenient time during academic duty days or during breaks. 
  • Inspection App and Routing: When safety staff complete an inspection, a report is emailed to the lab/shop supervisor. If corrective actions are required, the open inspection reports appear in the “Action Items” section of the RSS application. The following individuals are automatically cc'd on the inspection report: delegates in the RSS Group, department/college leadership, the safety representative for Research Foundation, and the College Safety Team. Other safety or facilities staff can also be tagged to help with specific corrective actions. For example, the Laser Safety Officer can be tagged to provide assistance with Class 4 laser corrective actions. 
  • Documenting Corrective Actions: When feasible, inspection-related conversations should be documented in the RSS system. You can also email your inspector or set up a consultation. The lab/shop supervisor or their delegates can take the following actions to communicate their corrective actions. 
    • After completing a corrective action, select "ready for verification" and provide a brief description of the action or a picture. This status change will automatically prompt your inspector to verify the corrective action as "resolved". Occasionally, the inspector may ask you follow up questions in order to verify the corrective action. 
    • After submitting a facilities work order or service request, select "ready for verification" and record the relevant service request number. The inspectors usually close out the finding as "no further action" which will stop the automated reminders from the RSS Inspect application. The lab/shop supervisor is still responsible for ensuring that the work order or service request is completed. Inspectors will confirm completion of “no further action” service requests during the next inspection. 
    • Use "discussion" to ask questions about specific corrective actions to your inspector, those cc'd on the inspection report, or other safety staff.
    • Use the “in progress” status to document your efforts to reach compliance. Beware that this option does not automatically send an email to the inspector. Inspectors will only see these comments if they specifically review your inspection report in RSS. 
  • Corrective Action Due Date: The corrective action due date is automatically 2 weeks after the inspection report is filed. This timing was selected by university Environmental Health & Safety since most inspections only result with a few straightforward corrective actions. Weekly email reminders will be sent for one month after the report is filed. The college provides a grace period to resolve most inspection reports within about a month. A member of the College Safety Team will reach out if the inspection report is open for more than a month to ensure that corrective actions are promptly completed by the lab/shop supervisor. 
  • Reasonable Extensions: Inspectors have discretion to provide reasonable extensions. Proactively communicate with the inspector for your lab/shop if you need accommodations to resolve complicated corrective actions or if your lab will be dormant during an extended absence. The lab/shop supervisor must present a clear action plan to the College Safety Team in order to request extensions. Extensions are not available for severe violations that pose immediate safety risks for personnel and/or property. 
  • University Safety & Compliance Consequences: University safety and compliance officers/committees can intervene if severe violations are discovered or if resolution is not achieved in a reasonable time. Be aware that safety and compliance officers/committees can swiftly implement consequences in response to severe violations that are immediately threatening to life and/or property. University officers/committees will provide written directions about their interventions to the lab/shop supervisor, the College Safety Team, and relevant leadership. The written explanation will specify the root cause of the enforcement actions and requirements to return to compliance. University officer/committee enforcement actions are scaled based on the hazards and any “patterns of noncompliance” for the lab/shop. Severe enforcement could involve confiscation of hazardous materials, deauthorization for hazardous activities, or lab closures. The quickest recovery process usually involves a voluntary halt in lab/shop operations until the most severe corrective actions are complete – with this approach most lab/shop activities can usually resume within a few days. College and department responses to noncompliance can also be implemented.

Safety & Compliance Documentation Audits

  • Safety training documentation: Safety training documentation is audited by the College Safety Team at least twice a year through the centralized RSS, CITI, CSULearn, and other relevant systems used at SJSU. 
    • Instructors for teaching labs/shops must ensure that safety training is documented and signed by enrolled students, teaching assistants, and the instructor before the hazard is used or before the first drop day, whichever comes first. 
    • Supervisors for research or technical staff labs/shops are encouraged to develop a “compliance calendar” for their operations (a template is available as an Environmental Health & Safety One Page Lesson). Research lab/shop safety training must be documented and signed before any personnel are granted unescorted access to the lab/shop and before they start work involving particularly hazardous materials, equipment, or activities.
  • Hazard Assessment and Chemical Inventory: At least twice a year, the College Safety Team audits hazard assessments, chemical inventory certifications, and group rosters in the RSS safety documentation system (ehs.ucop.edu). Departmental staff are responsible for these tasks in college teaching labs/shops, so this audit does not impact lab/shop course instructors.  
  • Specialized Safety or Compliance Documents: University safety and compliance officers/committees audit specialized safety documentation on a regular basis and will communicate requirements directly with lab/shop supervisors. These audits cover various documentation requirements such as registrations, authorizations, maintenance/operation logs, permits, and Standard Operating Procedures.

Specialized Hazard Inspections

University safety and compliance officers/committees conduct targeted inspections for specialized hazards such as class 3B & 4 lasers, vertebrate research, and radiation producing equipment. Inspection checklists and schedules for specialized hazards are provided by the relevant university safety and compliance officers/committees. 

Regulatory Authority Inspections

Regulatory authorities conduct inspections in SJSU labs/shops such as the Santa Clara County Hazardous Materials Compliance Division and the California Fire Marshal. University Environmental Health & Safety coordinates the inspections by regulatory agencies. The College Safety Team communicates the required corrective actions that result from these inspections to the lab/shop supervisors. 

Incident Investigation

Safety staff and department/college leadership conduct investigations after an accident, injury, or close-call occurs. This required incident investigation is described in the SJSU Illness & Injury Prevention Plan. The investigation starts after first-response steps are completed to address immediate safety concerns. The investigation usually involves interviews with the people involved with the incident and a review of related lab/shop safety documentation. Incident investigations usually yield a written guidance from safety staff or department/college leadership detailing the factors that contributed to the incident and recommendations to mitigate future risks. Safety staff often share de-identified lessons learned from these investigations with other similar operations on campus by updating training or documentation resources.