The Office of the Vice Chancellor for Research, Innovation, & Creative Activities Safety Oversight Committee (OSOC) is charged with promoting a safe environment for everyone working in research and teaching laboratories on campus. In an effort to ensure that safety issues identified by UCLA Environment Health & Safety (EH&S) during laboratory safety inspections or self-inspections are adequately addressed and corrected in a timely matter, the OSOC has established a 3-tiered Laboratory Safety Compliance Procedure (LSCP). Administration and enforcement of the LSCP is delegated to the faculty-led Chemical and Physical Safety Committee (CPSC).

The LSCP described below is designed to provide a progressive compliance process but may be bypassed in the event of conditions that are immediately dangerous to life or health. In such cases, CPSC will be notified by EH&S and the PI’s laboratory activities may be suspended, in whole or in part, in accordance with UCLA Policy 811.

Steps leading to the Laboratory Safety Compliance Procedure

EH&S conducts regular laboratory safety inspections to ensure and promote safe laboratory operations and has the right to do so at any time. After each inspection, reports are issued to the Principal Investigator (PI) responsible for the laboratory space describing safety findings to be corrected. There are two categories of safety findings:

  • Serious (high hazard) findings, which must be corrected immediately, and no later than 1 business day after the inspection report.
  • All other safety findings, which must be corrected within 30 calendar days of the inspection report.

PIs are expected to resolve findings within the indicated timeframes, subject to EH&S confirmation. If findings are not resolved within the indicated timeframes, EH&S will re-inspect the laboratory until correction has been confirmed. For Serious (high hazard) findings, re-inspections will be conducted approximately 2 and 3 days after the initial inspection. For all other safety findings, re-inspections will be conducted approximately 60 and 90 days after the initial inspection. If safety findings are still not resolved following the second re-inspection, the laboratory will be deemed noncompliant in safety by EH&S.

Laboratories identified by EH&S as low hazard (e.g. not containing pyrophoric chemicals or large volumes of flammable chemicals) are required by EH&S to conduct an annual self-inspection of their physical laboratory space using a self-inspection template provided by EH&S. Self-inspections are to be completed within 30 calendar days of initial notification by EH&S, and upon completion, the PI shall submit the self-inspection report to EH&S. If the self-inspection report is not submitted within 30 calendar days, EH&S will notify the PI of the deficiency. If the self-inspection report is not submitted within 60 days of the initial notification, the laboratory will be deemed noncompliant in safety by EH&S.

If EH&S determines that a laboratory is noncompliant in safety, as set forth above, the EH&S Chemical Hygiene Officer (CHO) will notify the CPSC Chair. Thereafter, a subcommittee of the CPSC, comprised of the Chair, the campus Chemical Hygiene Officer and a third committee member with relevant technical expertise, will initiate action to bring the laboratory into safety compliance, with such actions including but not necessarily limited to:

  • Directing EH&S to inspect a laboratory that has failed to self-inspect
  • Directing EH&S to assist the laboratory with correction of noncompliance.
  • Sending a warning letter to the PI and the PI’s department chair calling attention to the laboratory’s safety noncompliance, listing items requiring resolution, and highlighting the 3-tiered LSCP that can be initiated if the laboratory remains noncompliant.
  • Deferring immediate action and establishing a set time for re-evaluation.
  • Escalating to the LSCP.

Safety corrections that require infrastructure upgrades to be performed by Facilities Management will be considered on an individual basis. Alternative risk mitigation strategies may be approved by the Chair/Subcommittee, subject to consultation with EH&S or other relevant campus stakeholders such as the Dean and the Department Chair, in order to deem the laboratory compliant with safety requirements.

The three tiers of the LSCP are described below.

Questions can be sent to: cpsc@research.ucla.edu

Tier One

If the CPSC Subcommittee determines that a PI has failed to address safety requirements and is insufficiently responsive to EH&S, the CPSC Chair will issue a Tier One Memorandum.

The Tier One Memorandum will be sent to the PI and their Department Chair describing the noncompliance issue(s) and of the potential for suspension of laboratory operations. A new timeframe (typically 30 days) for completing corrective actions will be identified in the Memorandum.

It is recommended that the PI submit a written response to the Tier One Memorandum, detailing the corrective action taken or planned within the timeframe stated in the Tier One Memorandum.

Upon correction of the identified safety issues, the PI should notify EH&S. EH&S will then verify all corrections, inform the CPSC, and issue a Resolution notice to complete the LSCP Tier.

Tier Two

If the timeline identified in the Tier One Memorandum is not met, and reasonable progress towards resolution is not being made as determined by the CPSC Subcommittee, the CPSC Chair will issue a Tier Two Memorandum with a new timeline for correction.

The Tier Two Memorandum will be sent to the PI and the Department Chair describing the continued noncompliance issues and of the potential for suspension of laboratory operations. The PI must provide a formal written response to the CPSC Chair with reasons for the continued non-compliance and detailing the corrective action taken or planned within the timeframe stated in the Tier Two Memorandum.

Upon request, the PI and Department Chair may appear before the CPSC Subcommittee to discuss the proposed corrective action plan.

Upon correction of the identified safety issues, the PI shall notify EH&S. EH&S will then verify all corrections, inform the CPSC, and issue a Resolution notice to complete the LSCP Tier.

Tier Three

If the Tier Two timeline is not met, and reasonable progress toward resolution is not being made as determined by the CPSC Subcommittee, the CPSC Chair will issue a Tier Three Memorandum.

The Tier Three Memorandum will be sent to the PI, the Department Chair, EH&S, and the Vice Chancellor for Research, Innovation, & Creative Activities, detailing the continuing noncompliance and recommending that the PI’s operations be suspended until corrective actions are completed. The Vice Chancellor will determine if suspension is warranted following consultation with the CPSC, the Department Chair, the area Dean, and the Assistant Vice Chancellor for EH&S, as appropriate, and will take all necessary steps to effectuate the suspension.

During the suspension period, the PI and Department Chair may request to appear before the CPSC to explain why laboratory operations should be reinstated and concurrently present a formal written corrective action plan to resolve findings.

Upon correction of the identified safety issues, the PI shall notify EH&S. EH&S will then verify all corrections, inform the CPSC and the Vice Chancellor, and issue a Resolution notice to complete the LSCP Tier. Any restrictions on laboratory access will be removed and the suspension formally lifted.

Approved: 1/8/2014
Revised: 12/17/2014, 9/28/2026