Personnel that do not handle live animals do not need to be listed on the protocol. All personnel who plan to work with animals or are listed on an animal care and use protocol must complete the Initial Mandatory Education before the protocol will be approved and studies can commence. All personnel being added to a currently approved protocol must also complete the initial mandatory education before the amendment will be approved and access to the animal facility granted. Other training courses (i.e. from another institution) may meet or exceed the requirements if all elements of the course have been covered and a documented successful test score is provided. Responsibility for determining equivalency rests with the Office of the Attending Veterinarian (IACUC Office - provide course details, test scores, and information to Angela Croucher). Any courses completed to meet mandatory education do not count towards meeting your Continuing Education requirement detailed below.

Personnel that do not handle live animals do not need to be listed on the protocol. All research personnel listed on any approved animal care and use protocol will be required to complete two* Continuing Education courses every three years regardless of the number of active protocols on which they are listed. Though selection of the elective course to fulfill this requirement is flexible, there is an expectation that the PI will take courses relevant to the species being studied and/or the procedures (i.e. surgery) being used. OAV or DLAR staff can be contacted to determine which course would be most valuable.

*“Animal Use Review for University of Kentucky personnel” which can be accessed through AALAS Learning Library AND one course, of your choice, from the IACUC approved list of courses.

Research consultants may be brought in for short term training or procedural expertise. Consultants are required to complete the mandatory education and to be listed on the IACUC protocol if their work involves physical handling, surgical manipulation, or physical interaction with the protocol's animals.

Decisions regarding exceptions will be considered by the IACUC Chair and Attending Veterinarian.   

Participation in the OHSP is based on having contact with live vertebrates and potential exposure to hazardous agents. The OHSP is applicable to the following personnel:

• Full time, part time, and temporary personnel involved in animal care in UK units that house animals for research and teaching. 
• Research investigators and their technical/research staff (includes post-docs, graduate students and undergraduate students). 
• Instructors involved with animal related work. 
• Other UK personnel who may be reasonably expected to come in contact with vertebrate animals, their viable tissues, body fluids or wastes (some personnel in facilities management, security, custodial services). 

The Office of the Attending Veterinarian (OAV) identifies and notifies those personnel listed on animal use protocols that are required to participate in the OHSP.  The Division of Lab Animal Resources identifies and notifies its personnel for participation in the OHSP.

Minors:

Minors under the age of 14 are not permitted inside of any research laboratory, greenhouse, or animal facility at UK unless it is for UK sponsored programs which are designed for youth under the age of 14 and which have documented training and safety policies.  Due to the short duration of the activity, minors are typically not enrolled in the OHSP, however, UK has established and implemented the policy Minors in Research Laboratories or Animal Facilities (pdf, 3pgs).  This policy requires that a risk assessment be conducted of all planned tasks and specifies all personal protective equipment (PPE) and training requirements that must be implemented to allow for minors to participate in any sponsored programs involving animals.

Medical Surveillance is initiated for those personnel identified as required to participate in the OHSP. The following steps are initiated by the affected personnel for participation in the OHSP.

Initial Review

1. Completion and submission to University Health Service (UHS) of the online “Animal Handler Medical Surveillance Form” by the affected individual. Instructions for Access through UK MyChart (PDF, 2pgs).
2. UHS conducts a clinical review based on the information provided on the “Animal Handler Medical Surveillance Form” in determining if no further action is required, more information is required, or an evaluation is required by a Licensed Healthcare Professional to include any required immunizations and medical screening.
3. Once the affected individual has been approved by UHS to have contact with live vertebrates and potential exposure to hazardous agents, they may begin work with live vertebrates.

Annual Review

At the end of 12 months of participation in the OHSP, UHS will notify affected personnel that the “Animal Handler Medical Surveillance Form” shall be resubmitted and the steps indicated in the initial review are repeated.  UHS shall conduct a clinical review in determining if any changes have occurred to the individual’s hazards exposure risk and medical disposition.

Special Review

Any amendment to an animal protocol that indicates any changes that would potentially increase an existing or introduce a new hazard exposure shall require an evaluation by UHS. The affected personnel and their supervisor must ensure that the "Animal Handler Medical Surveillance Form" is kept current with respect to any changes in job or task and any changes in animal contact or exposure to hazardous agents. Significant changes in activities may require a resubmission.

All animal care and use protocols submitted to the Institutional Animal Care and Use Committee (IACUC) are reviewed in their entirety by the UK Division of Environmental Health and Safety (EH&S).  The review includes, but is not limited to identifying all hazardous agents (chemical, physical, and biological stressors), conducting a risk assessment based on the agents to be used and their application, identifying and requiring any hazard control mechanisms, e.g., engineering controls, work practices, personal protective equipment, providing instructions on the handling and disposition of any generated wastes.

Additionally, any anticipated possession and use of infectious or potentially infectious microorganisms, hazardous biological materials and/or recombinant or synthetic acid containing material are subject to review and approval by the Institutional Biosafety Committee (IBC).  Any anticipated possession and use of radioactive materials are subject to review and approval by the Radiation Safety Committee (RSC).  Each committee stipulates the required control mechanisms, PPE, waste disposition, and training requirements. EH&S has standing membership on each of these oversight committees.  As an element of its protocol review, EH&S confirms approvals from these oversight committees during its reviews.

The Director of EH&S has standing membership on the IACUC and serves as the liaison to the IACUC on all matters related to environmental health and safety, as well as those identified by the aforementioned oversight committees that impact affected personnel participating in the OHSP.  This includes all personnel listed in all animal care and use protocols.  Approval by the IACUC for any animal care and use protocol is contingent upon prior approval by EH&S and the aforementioned committees.

The Commonwealth of Kentucky - Department of Housing, Buildings and Construction (HBC), has review and inspection authority for compliance with the Kentucky Building Code (KBC).  In 2006, EHS pursued and obtained the authority to perform plan (project) review, inspection authority, and approval for construction and renovation projects in certain University facilities. HBC retained jurisdiction for all capital construction projects involving more than $1,000,000 and all healthcare building projects. 

The plan review/approval process is coordinated by the University Fire Marshal which is a department within EH&S.  All projects inclusive of those greater than $1,000,000 are reviewed by all four departments within EH&S (Environmental Management, University Fire Marshal, Occupational Health and Safety, and Research Safety) against all applicable codes, standards, and industry accepted guidelines.  Project meetings are routinely conducted that allow for input by all stakeholders that includes the end users of the areas affected, engineering and maintenance personnel.

UK controls exposures to stressors (occupational hazards) via the application of engineering controls, work practices, and the use of PPE.  During the EH&S review, any hazard mitigation is addressed utilizing the concept of the hierarchy of controls.  Every effort is employed to isolate personnel from hazards with engineering controls.  In the event engineering controls are not effective, personnel work practices are modified to mitigate hazard exposure.  PPE may be required to complement other controls. 

• Chemical Fume Hoods 
  
  One of the primary hazard control mechanisms utilized within UK laboratories for the control of non-biological airborne hazards are chemical fume hoods.   At a minimum, EH&S performs a functional evaluation of every Chemical Fume Hood on an annual basis.  EH&S has established technical and performance standards that relate to the placement and functional operation of Chemical Fume Hoods.
• Biological Safety Cabinets (PDF, 6pgs) 
  
  These control mechanisms are utilized within UK laboratories for the control of airborne biological hazards.  EH&S has established policies and procedures related to the daily use, cleaning, decontamination, routine maintenance, and annual certification of Biological Safety Cabinets (BSCs).
• Animal Transfer Stations 
  
  Animal Transfer Stations (ATSs) are utilized to contain particulate allergens when rodent caging is opened for routine husbandry or research activities.  These units provide High Efficiency Particulate Air (HEPA) filtration of both the supply and exhaust air.  These units are designed for allergen control and provide much less restricted work area than BSCs. 
• Individually Ventilated Caging Systems 
  
  These systems are utilized to provide containment of infectious agents as well as allergens.  The system cages are typically manipulated within a BSC.   The systems have an isolating capacity which protects both the housed animals and the working personnel via HEPA filtration of both supply and exhaust air which maintains cage integrity via self-closing valves when removed from rack.  Airflow within the individually ventilated cages provides a barrier which protects the animal as well as personnel from airborne infectious agents.
• Cage Dumping Systems
  
  These systems are utilized to control airborne exposures to particulates during the removal of bedding from cages and incorporate the use of downdraft local exhaust systems or HEPA filtration.  No air from the local exhaust systems is recirculated -100 percent exhaust.
• Scavenging Systems
  
  Where the use of a Chemical Fume Hood is not feasible, scavenging systems incorporating local exhaust ventilation or charcoal absorption are utilized.   These systems are utilized to prevent exposure to anesthetic agents.  

• Work Practices/PPE 
  
  All required work practices and PPE are identified and specified during the review of animal care and use protocols conducted by EH&S.  General work practices and PPE requirements are specified in the following:

  • UK Biosafety Manual (PDF, 41pgs)

  • UK Chemical Hygiene Plan (PDF, 124pgs)

  • UK Radiation Safety Manual (PDF, 64pgs)

For routine operations conducted within animal housing areas associated with animal husbandry and care, hazard assessments of tasks and training  have been conducted  in accordance with 29 CFR 1910.132.  This is inclusive of providing the required PPE as identified in the associated risk assessment.

Animals are transported through public areas to access laboratory space or to be transferred between animal facilities.  Rodents are transported through public areas in micro-isolator cages or shipping containers in a closed transport cart or on a laboratory cart completely covered with a drape. Animals and soiled equipment are transported between floors in freight elevators to avoid contact with individuals not associated with the animal care and use program. Animals other than rodents are transported in crates and the crates are covered with a drape. Soiled equipment is covered with drapes for transport outside of DLAR facilities.

Inspections of all areas housing or holding animals for greater than 12 hours and all survival and non-survival surgery sites are performed semiannually by a subcommittee of the IACUC. Other areas that do not house animals for over 12 hours and areas where activities with minimal impact on animal wellbeing (behavior testing labs, etc.) are inspected once a year or more frequently as needed.  An EH&S representative accompanies the subcommittee on inspections and evaluates the affected areas for any environmental health and safety hazards.  Any hazards needing mitigation are then communicated by EH&S to the appropriate contacts and monitored for correction.

OAV offers a Training Requirements Checklist (PDF, 1pg) to assist personnel in locating and completing all training resources relevant to animal research and lab work. In addition to IACUC requirements, EH&S resources are identified. Occupational Health and Safety training is a mandatory component of the OHSP.  The training provides information on the risks associated with working with laboratory animals which include:

• Sharps Exposure
• Allergies
• Chemical Exposure
• Bites and Scratches
• Strains, Sprains
• Zoonotic Diseases
• Other Physical Injuries
• Biologic Agent Exposure

The training further provides information on the transport animals, PPE, zoonotic diseases, reporting injuries/illnesses, and practices to reduce exposures.

During its review of animal care and use protocols, EH&S verifies that all required environmental health and safety training has been completed by those affected.  As relates to working in a laboratory environment where hazardous chemicals are utilized, there are three primary online training modules that all employees must complete prior to commencing laboratory activities.  These are: 

1. Chemical Hygiene Plan/Laboratory Safety
2. Hazardous Waste Handling and Disposal (E-Trax Waste Handling)
3. Fire Extinguisher Use

In addition to the IACUC Initial Mandatory Education and internal training conducted by DLAR for its staff, EH&S provides required environmental health and safety training courses.  Various tools are made available to affected personnel to provide guidance on conditions that indicate specific training that is required.  These include but are not limited to:

• Laboratory and Non-Laboratory Safety Training Checklists 
• EH&S Training Matrix
• Environmental Health and Safety Requirements for Research Grants and Contracts Checklist  (this document is forwarded by OSPA to researchers with an accompanying memo from  the  EH&S Director)

Various types of engineering controls/systems are utilized to control exposures to affected personnel and protect the environment. Performance and operational integrity mechanisms have been implemented to ensure these control/systems are providing the necessary protection and maintaining effective performance. Below are the various standard controls/systems utilized:

• Chemical Fume Hoods 
  
  At a minimum, EH&S performs a functional evaluation of every Chemical Fume Hood on an annual basis.  EH&S has established technical and performance standards that relate to the placement and functional operation of Chemical Fume Hoods.  Evaluation and performance criteria are derived from ANSI/AIHA Z9.2-2012.
  
  All Chemical Fume Hoods are required to have face velocities between 80-120 feet per minute (fpm) with the sash at the designated working height. Working heights are most commonly 12 or 18 inches and are marked with a bright yellow chemical fume hood sticker indicating where the sash must be positioned and the measured face velocity.  Any chemical fume hood not meeting the minimum performance criteria is taken out of service and a sticker placed on the hood to warn personnel of its status and to seal the sash to prevent use. Operations requiring the use of the chemical fume hood are suspended until repairs can be made.
• Biological Safety Cabinets (PDF, 6pgs)
  
  UK has established and implemented policies and procedures related to the daily use, cleaning, decontamination, routine maintenance, and annual certification of BSCs. Only approved vendors (PDF, 1pg) may be utilized to certify, repair or decontaminate biological safety cabinets or laminar flow benches on the UK campus.
• Animal Transfer Stations
  
  ATSs are certified every two years by an approved vendor to ensure design and performance standards are being met.  The certification includes HEPA filter replacement.

• Individually Ventilated Caging Systems

  Performance monitoring and HEPA filter replacement is performed locally by DLAR staff.

• Cage Dumping Systems
  
  Performance monitoring and filter replacement of the HEPA filtered local exhaust systems is performed locally by DLAR staff.   EH&S routinely monitors the performance of these units.

• Scavenging Systems
  
  Activated charcoal scavenging canisters are replaced after 12 hours of use or after the canisters reach the designated maximum weight as stated by the manufacturer.  Depending on the location, the canisters are replaced by either DLAR staff or the investigator.

• Autoclaves (PDF, 5pgs)
  
  UK has established and implemented policies and procedures related to safe autoclave operation, installation of new autoclaves, routine preventive maintenance and repairs, appropriate signage, training and verification of autoclaves. These policies and procedures are best practice recommendations; however, specifics of daily use and routine maintenance shall be performed according to manufacturers’ recommendations. These policies and procedures apply to all laboratories at UK which generate biohazardous waste with the exception of laboratories operating at Biosafety Level 3.

• Sanitary Wastewater Discharge Monitoring
  
  An Industrial User Wastewater Discharge Permit has been issued to UK from LFUCG (Lexington-Fayette Urban County Government) through authority from the Kentucky Division of Water and the US EPA as part of the Clean Water Act. This Permit authorizes discharge from UK to the city's sanitary sewer system through specifically permitted outfalls. The Permit requires semiannual monitoring events take place for several specific constituents as well as a calculation of corresponding flow rates all which must be reported to LFUCG on a semiannual basis.  All monitoring and reporting is performed by EH&S.

• Room Ventilation 
  
  All rooms where animals are housed have ventilation systems appropriate for the species and the type of animal use.

• Fire/Life Safety Systems

  The UK Fire Marshal’s Office maintains information related to the status of each facility’s fire/life safety system and evacuation plan and inspects all fire extinguishers on an annual basis.  The systems inspection/testing listed below are conducted by the Physical Plant Division (PPD) or their designee. 

  • Fire Alarm Inspection – performed by PPD per NFPA 72

  • Sprinkler System Inspection – performed by contractor per NFPA 13

  • Fire Pump Inspection – performed by contractor per NFPA 13

  • Emergency Lighting Testing – performed by PPD per KBC

  • Fire Escape Inspection – performed by contractor

All employees are required to report all job-related injuries or illnesses (Administrative Regulation 6:3 (PDF, 4pgs)).  UK has established mechanisms for reporting all accidents, injuries or illnesses entitled Report Your Accident.  To ensure compliance with NIH Guidelines for Recombinant DNA, UK has additionally established a reporting procedure for occupational injuries or exposures in laboratories (PDF, 2pgs).

As part of its protocol review, EH&S communicates all hazard information related to chemical, physical, and biological stressors to personnel through Special Animal Safety Protocol (SASP) documents and hazardous agent awareness cage cards. The information communicated includes emergency contact information, characteristics of the agent and symptoms of exposure, minimum personal protective equipment (PPE) required, and required procedures, equipment, and disposal for working with animals exposed to these hazards. All SASP documents are available online to all personnel.

Online verification of safety training completion is available to all personnel including associated supervisors.

Additionally, EH&S analyzes and trends all injuries/illnesses that reported via the primary or secondary reporting procedure referenced in Report Your Accident.  Analyses and trends are shared with affected units to promote awareness and used by EH&S for targeting areas needing its services.

Building Emergency Action Plans (BEAPs) have been established for all buildings with human occupancy and where animals are housed. The BEAP provides basic direction to all building occupants regarding the needed actions to take during an emergency or crisis. It also identifies building and floor coordinators who take the lead in creating and updating the plan. Additionally, they may assist in enacting required emergency procedures should the need arise.
 

General program oversight and recommendations for improvements are provided to the IACUC and animal care staff by the Director of EH&S during the semiannual inspection and program review process as required by the Public Health Service (PHS) Policy on Humane Care and Use of Laboratory Animals (Policy), Section IV.B.1.-3., the Guide for the Care and Use of Laboratory Animals (Guide), the Guide for the Care and Use of Agricultural Animals in Research and Teaching, and the Animal Welfare Act (AWA) regulations, as applicable. Submission of semiannual reports to the Institutional Official is a condition of this institution’s Animal Welfare Assurance with the NIH Office of Laboratory Animal Welfare (OLAW).

• Guide for the Care and Use of Laboratory Animals. 2011. National Academy Press, Washington D.C. 2011.
• Public Health Service Policy on Humane Care and Use of Laboratory Animals. 1986. Reprinted 2002. U.S. Department of Health and Human Services, Washington D.C. (Available from: Office of Laboratory Animal Welfare, National Institutes of Health, Bethesda, MD) 16pp.
• Occupational Health and Safety in the Care and Use of Research Animals. Committee on Occupational Safety and Health in Research Animal Facilities, National Research Council. 1997. National Academy Press. Washington D.C.
• Guide for the Care and Use of Agricultural Animals in Research and Teaching (PDF, 227pgs). 2020. Federation of Animal Science Societies.