University Hospital Policies and Procedures

Table of Contents
ID Title Format
0-0 Table of Contents (in Adobe PDF format) (in MS Word DOC format)

General Safety and Health
ID Title Format
1-1 Hospital Safety Program (in Adobe PDF format) (in MS Word DOC format)
1-2 Reserved -
1-3 Safety and Health Training (in Adobe PDF format) (in MS Word DOC format)
1-4 Compressed Gases and Cryogenic Liquids (refer to UH Admin P&P, EC:0028) -
1-5 Confined Space Operations (in Adobe PDF format)
1-6 Fire and Life Safety for Construction (refer to EH&S policy 5-11) -
1-7 Emergency Safety Showers and Eyewashes (refer to UH Admin P&P, EC:0039)
1-8 Hearing Conservation Program (refer to UH Admin P&P, EC:0043) -
1-9 Manual Material Handling (in Adobe PDF format) (in MS Word DOC format)
1-10 Machine Shop Safety (University EH&S Policy) (in Adobe PDF format)
1-11 Powered Industrial Trucks (in Adobe PDF format) (in MS Word DOC format)
1-12 Computer Work Stations (in Adobe PDF format) (in MS Word DOC format)
1-13 Welding, Cutting and Brazing (in Adobe PDF format) (in MS Word DOC format)
1-14 Testing Rooms for Negative Pressure (in Adobe PDF format) (in MS Word DOC format)
1-15 Hand Tools and Portable Power Tools (in Adobe PDF format) (in MS Word DOC format)
1-16 Temporary Stairways, Ladders and Portable Ladders (in Adobe PDF format) (in MS Word DOC format)
Food Safety (University EH&S Policy) (in Adobe PDF format)

Emergencies
ID Title Format
2-1 Hospital Fire Response Plan (in Adobe PDF format) (in MS Word DOC format)
2-2 Ambulatory Surgery Center Fire Response Plan (in Adobe PDF format) (in MS Word DOC format)
2-3 Ambulatory Care Pavilion Fire Response Plan (in Adobe PDF format) (in MS Word DOC format)
2-4 Hospital Off-sites Fire Response Plan (in Adobe PDF format) (in MS Word DOC format)
2-5 Flood Response (refer to UH Admin P&P, EC:0032) -
2-6 Hazardous Materials Spill Plan (refer to UH Admin P&P, EC0054) -
2-7 Emergency Procedures for Ethylene Oxide Release (in Adobe PDF format) (in MS Word DOC format)

Electrical Safety
ID Title Format
3-1 Electrical Extension Cords (refer to UH Admin P&P, EC:0027) -
3-2 Control of Hazardous Energy (Lockout/Tagout) (in Adobe PDF format)
3-3 Portable Heating Equipment (Refer to UH Admin P&P, EC:0027) -
Campus Electrical Safety (in Adobe PDF format)

Chemical Safety and Laboratory Safety
ID Title Format
4-1 Hazard Communication / Right-to-Know (refer to UH Admin P&P, EC0053) -
4-2 Laboratory Safety Manual (includes Chemical Hygiene Plan and Laboratory Safety Guide) (in Adobe PDF format)
4-3 Reserved -
4-4 Reserved -
4-5 Formaldehyde Safety (in Adobe PDF format) (in MS Word DOC format)
4-6 Chemical Fume Hoods and Biological Safety Cabinets (in Adobe PDF format) (in MS Word DOC format)
4-7 Reserved -
4-8 Monitoring for Hazardous Air Contaminants (in Adobe PDF format) (in MS Word DOC format)
4-9 Selecting, Using, Handling, Storing, Transporting and Disposing of Hazardous Materials (in Adobe PDF format) (in MS Word DOC format)
Nitric Acid Security Plan (University EH&S Policy) (in Adobe PDF format)
Registration of Laboratories (University EH&S Policy) (in Adobe PDF format)
Laboratory Close Out (University EH&S policy) (in Adobe PDF format)

Fire Safety
ID Title Format
5-1 Holiday Decorations (Refer to UH Admin P&P, EC:0027) -
5-2 Furnishings, Bedding, and Decorations (refer to UH Admin P&P, EC:0027) -
5-3 Fire and Smoke Barrier Penetrations (in Adobe PDF format) (in MS Word DOC format)
5-4 Maintenance of Buildings to Life Safety Code Standards and Statement of Conditions (in Adobe PDF format) (in MS Word DOC format)
5-5 Fire Protection System Impairments (in Adobe PDF format) (in MS Word DOC format)
5-6 Reserved -
5-7 Fire Warden Program (refer to UH Admin P&P, EC:0027) -
5-8 Fire Watch (in Adobe PDF format) (in MS Word DOC format)
5-9 Reserved -
5-10 Fire Extinguishers (in Adobe PDF format) (in MS Word DOC format)
5-11 Interim Life Safety Measures (refer to UH Admin P&P, EC:0044) -
5-12 Fire Protection Systems (in Adobe PDF format) (in MS Word DOC format)
5-13 Reserved -
5-14 Fire Drills (in Adobe PDF format) (in MS Word DOC format)
5-15 Code Red (in Adobe PDF format) (in MS Word DOC format)

Radiation Safety
ID Title Format
6-1 University Hospital Radiation Safety Committee Policies and
Procedures for Use of Ionizing Radiation
(in Adobe PDF format)
6-2 Overview to Radioactive Material Licensing Regulations (in Adobe PDF format)
6-3 Radioactive Material Licensing Procedure (in Adobe PDF format)
6-4 Senior Investigator Sabbatical or Leave of Absence from
an Authorized Radiation Safety Operation
(in Adobe PDF format)
6-5 Decommissioning of Laboratory Radiation Control Areas (in Adobe PDF format)
6-6 X-Ray Diffraction Guidelines (in Adobe PDF format)
6-7 Radiation Emergency Spill Procedures (in Adobe PDF format)
6-8 Laser Safety (in Adobe PDF format)

Personal Protective Equipment
ID Title Format
7-1 Personal Protective Equipment (refer to UH Admin P&P, EC0050) -
7-2 Respiratory Protection (refer to UH Admin P&P, EC:0038) -

Environmental Protection
ID Title Format
8-1 Chemical Hazardous Waste Management (in Adobe PDF format) (in MS Word DOC format)
8-2 Integrated Pest Management (refer to UH Admin P&P, EC:0047) -
8-3 Asbestos Management (in Adobe PDF format) (in MS Word DOC format)
8-4 Regulated Medical Waste Management (refer to UH Admin P&P, EC:0026) -
8-5 Hazardous Drugs Management (refer to UH Admin P&P, EC:0048) -
8-6 Collection and Disposal of Sharps from Private Residences (in Adobe PDF format) (in MS Word DOC format)
8-7 Waste Determination (refer to UH Admin P&P, EC:0045) -
8-8 Shipping of Infectious Substances (in Adobe PDF format) (in MS Word DOC format)
8-9 Universal Waste Management (in Adobe PDF format) (in MS Word DOC format)
8-10 Pharmaceutical Waste Management (in Adobe PDF format) (in MS Word DOC format)
8-11 Mercury Management (in Adobe PDF format) (in MS Word DOC format)
8-12 Hazardous Waste Contingency Plan and Emergency Procedures (in Adobe PDF format) (in MS Word DOC format)

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