Systemwide EHS Annual Report Data Request Form 2022

Systemwide EHS Annual Report Data Request Form 2022

Data collection and analysis entails the following goals: - Make data-driven Risk Management decisions. - Compare campuses' activities and results. - Close the CSA Audit. - Meet the intent of the Systemwide Business & Finance Balanced Scorecard. The Plan for Evaluating the Annual Reports data is found in the EHS SharePoint site at this link - TBD

Campus*

Select

Your Name*

Director name, phone #

Email Address*

Additional Report Recipients

You can add contact information for the Campus President, VP (for example), or anyone else who may be responsible for planning, budgeting, and advocating EHS needs. This is optional. Please include name, title, and email address.

Scope of Campus and EHS Operations

Enter your data. This will help determine staffing rates per Net Assignable Square Footage (NASF) and budget rates per NASF. Lab NASF may factor in as well. NASF databases will be found at the following facilities database in the SharePoint site or any updates to it.

NASF - https://csyou.calstate.edu/groups/risk/wercs/EHS/EHS-Directors/Shared%20Documents/Annual%20Reports%20from%20Campuses/Facilities%20Databases/2020-21%20Building%20Net%20Assignable%20Square%20Footage-NASF.pdf

Research NASF - https://csyou.calstate.edu/groups/risk/wercs/EHS/EHS-Directors/Shared%20Documents/Annual%20Reports%20from%20Campuses/Facilities%20Databases/NSF%20Research%20Net%20Assignable%20Sq%20Ft%20Institutions%202019.pdf

EHS Budget - Haz Waste Waste*

Haz Waste disposal costs for the following: • Hazardous Waste • Universal Waste • Medical Waste • Radioactive Waste • Total Regulated Waste

EHS Budget - Salaries*

Include salaries for any personnel responsible for EO 1039 and environmental compliance activities that generally fall under EHS.

EHS Budget - Operations*

Include vendors and any other expenditures not captured under waste cost and salaries. Note - Fixed systems (i.e. fire supression system work) is facilities. Fire drills, etc. is EHS.

EHS Staffing - MPP (enter number)*

FTE dedicated to EO 1039 and environmental health compliance; use partial FTE for employees also covering other responsibilities.

EHS Staffing - Non-MPP Staff*

FTE dedicated to EO 1039 and environmental health compliance; use partial FTE for employees also covering non-1039 responsibilities.

Embedded EHS Professionals*

FTE dedicated to EO 1039 and environmental health compliance; use partial FTE for employees covering non-1039 responsibilities. These report up to a non-EHS organization such as the Sciences. 12/16 note - include only persons with 1/2 FTE EHS responsbility.

BioSafety Officer*

Please enter the name or names of the BioSafety Officers and indicate whether they cover the the campus or a specific school or department (i.e., Chemistry). If no BSO is in place, please explain why.

Chemical Hygiene Officer*

Please enter the name or names of the Chemical Hygiene Officers and indicate whether they cover the the campus or a specific school or department (i.e., Chemistry). If no CHO is in place, please explain why.

Radiation Safety Officer*

Please enter the name or names of the Radiation Safety Officers and indicate whether they cover the the campus or a specific school or department (i.e., Chemistry). If no RSO is in place, please explain why.

Department Safety Coordinators (EHS / EO 1039 Focus)*

Enter a number. Department Safety Coordinators work in other departments and have some EHS responsibilities. However, their main role is not EHS-focused (such as Instructional Support Technicians).

Student Employees Employed during the FY (#)*

Please provide an FTE equivalent rather than a head count.

Number of Stages in use

Theater and performing arts programs have been an area of risk and area of focus in recent years amongst EHS departments.

Agriculture Research and Instruction Operations

These are sizeable agriculture operations which may have heavy equipment, machine shops and/or large animals, not to mention pesticide management issues. They also have areas dedicated to ag that are a significant portion of their campus footprint.

Yes

Housing Operational Capacity (Campus & Auxiliary Operated)

Data will be derived from spreadsheet at this link - https://csyou.calstate.edu/groups/risk/wercs/EHS/EHS-Directors/Shared%20Documents/Annual%20Reports%20from%20Campuses/Facilities%20Databases/Fall%202021%20Occupancy%20Report.pdf

Key Performance Indicators (KPI's)

Data in this section will establish goals and target for key objectives in the CSU EHS programs. Our systems and processes can provide accurate enough data to provide status reports and for further goal setting. Some data is found centrally and others are provided by the campus.

RSS Activities

Data will be derived from the RSS Dashboard at the time of reporting. We will compare individual campuses to CSU Averages and compare the CSU Average to a 95% target for all noted metrics relevant to inspections, hazard assessments, and chemical inventories.

Hazard Assessments: “Fully Acknowledged” and "Acknowledged"
Inspections: “Resolved Findings” and "Overdue Findings"
Chemical Inventories:
Ensure “RPs w/ Chemical Hazards” complete chemical inventories (“RPs with Inventories” ÷ “RPs w/ Chemical Hazards”)
"Inventories Certified"

EHS Training

Please enter your training compliance numbers in this section.

Meanwhile, Systemwide Learning and Development will partner with SRM and the EHS Affinity Group to develop an EHS training compliance dashboard similar to this - https://app.smartsheet.com/dashboards/WF52Jr8FjWpp5Xp6fmv2VW4cFWJMrPWG8rhQJFF1

Expected completion for this dashboard is October 2023.

Employee IIPP Training Compliance

Employee Haz Comm Training Compliance

Employee Haz Waste Training Compliance

Employee Lab Safety Training Compliance

Safety Equipment Inspections

Emergency showers, eyewash stations inventoried

# of emergency showers, eyewash stations. List a combo units as one of each.

Emergency Showers, Eyewashes & Comb Units Flushed by Due Date

% of individual units that did not miss two or more monthly flushes over fiscal year period

Fume Hoods Inventoried

List only those in use and not those that are out of operation. Enter a number.

Fume Hoods Inspected by Due Date

Number inspected annually

Fume Hoods Inspected %

percent inspecte

BioSafety Cabinets Inventoried

Biosafety cabinets used for biological material containment to protect lab workers or students (not for product protection). Do not include biosafety cabinets that are out of operation.

BioSafety Cabinets Inspected by Due Date

Biosafety cabinets used for biological materials that were certified over fiscal year period

BioSafety Cabinets Certified %

% biosafety cabinets certified

Fire Extinguishers Inventoried

Number

HVAC Systems Inventoried

Cal/OSHA Inspection Requirement §5142 Inspection and Maintenance: - Inspect at least annually and correct problems found. - Documented in writing and record name of individuals performing them, date and specific findings and actions taken. - Make records available. Note – Applicable to all buildings.

Enter a number number of Air Handler Units. Regarding COVID HVAC improvements - this may be assessed via a separate survey but for consistency year to year, it is not addressed in this survey.

HVAC Systems Inspected by Due Date

Enter a number.

Include if all applicable components associated with the AHU were inspected.

HVAC Systems Inspected %

Percent of AHU's Include if all applicable components associated with the AHU were inspected.

Safety Program Reviews

EHS programs need review over time to strive for relevance. The programs noted here either have specific regulatory language requiring review or the CSU considers them a priority for review.

Notes on EHS program reviews:

Regulatory programs focus on high-risk activities correlating to serious incidents.
Focusing on injury and lost time rates alone does prevent serious incidents or death.
Regulators require periodic reviews for certain programs. See Program Review Requirements Spreadsheet.
Where Cal/OSHA does not specify, the CSU requires a review every three years.

Aerosol Transmissible Diseases

Check if annual review was completed per https://www.dir.ca.gov/Title8/5199.html requirements. Referring Employers - Infection control procedures required; full plan not (Campuses would probably fall into this category if ATD was applicable to them.) Employers with Occupational Exposures - Exposure Control Plan required

Infection Control Procedures were reviewed within a year.

Infection Control Procedures are required but were not reviewed in the past year.

Exposure Control Plan was reviewed within a year.

Exposure Control Plan is required but was not reviewed in the past year.

Aerosol Transmissible Diseases Program is not applicable at my campus.

Asbestos

California's Asbestos Notification Law, California Health and Safety Code Sections 25915-25919.7, requires notification if asbestos containing construction material is present in public buildings

Asbestos notification was completed within a year.

Asbestos notification was not completed in the past year.

Asbestos notification is not applicable to my campus.

Bloodborne Pathogens

Check box if completed. Campuses who require an exposure control plan will need to review and update it annually or when relevant changes occur. See https://www.dir.ca.gov/Title8/5193.html.

An Exposure Control Plan is required at my campus and the program has undergone annual review and/or update with any changes.

The Exposure Control Plan was not reviewed within a year.

BBP program is not applicable at my campus.

Permit-Required Confined Space

Written program required when employer decides that employees will enter PRCS. Review the permit space program, using the canceled permits retained under subsection (e)(6) within 1 year after each entry and revise the program as necessary, to ensure that employees participating in entry operations are protected from permit space hazards. Campuses with a PRCS program will need to review annually. See https://www.dir.ca.gov/Title8/5157.html.

Employees at my campus enter permit-required confined spaces and permits have been reviewed within one year of entry and the program was revised if necessary after review of the permits.

The program review requirements were not met in the past year.

Permit-required confined space program is not applicable at my campus.

Arc Flash Protection / Electrical Safety

See NFPA 70E.

Arc Flash Protection / Electrical Safety program reviews are completed.

Any required Arc Flash Protection / Electrical Safety Program reviews are required but not current.

Arc Flash Protection / Electrical Safety Programs are not applicable at my campus.

Emergency Action Plan

The Emergency Action Plan shall be in writing. No review frequency was found so CSU is requiring review every three years. See https://www.dir.ca.gov/Title8/3220.html.

The Emergency Action Plan has been reviewed within three years.

The Emergency Action Plan has not been reviewed within three years.

Fire Prevention Plan*

The Fire Prevention Plan shall be in writing. No review frequency was found so CSU is requiring review every three years. See https://www.dir.ca.gov/Title8/3221.html.

The Fire Prevention Plan was reviewed within three years.

The Fire Prevention Plan was not reviewed within three years.

Hazard Communication

See https://www.dir.ca.gov/Title8/5194.html. Develop, implement, and maintain at the workplace a written hazard communication program.

The HazCom program was reviewed within three years.

The HazCom program was not reviewed within three years.

HAZWOPER

Is your campus a VSQG, SQG, or LQG based on EPA regulations? Has your written safety plan been reviewed within the last three years? See https://www.dir.ca.gov/Title8/5192.html. of, hazardous substances without regard to the location of the hazard. ...Employers shall develop and implement a written safety and health program for their employees involved in hazardous waste operations. The program shall be designed to identify, evaluate, and control safety and health hazards, and provide for emergency response for hazardous waste operations...emergency response plan...PPE program. The site emergency response plan shall be reviewed periodically and, as necessary, be amended to keep it current with new or changing site conditions or information. Review the site emergency response plan annually; review the PPE program portion effectiveness and the overall site health and safety plan at least every three years.

Written safety plan was reviewed within three years.

Written safety plan was not reviewed within three years.

The HAZWOPER Program is not applicable to my campus.

Hearing Conservation

See https://www.dir.ca.gov/Title8/5097.html. ...administer a...program...whenever employee noise exposures equal or exceed an 8-hour time-weighted average sound level (TWA) of 85 decibels measured on the A-scale (slow response) or, equivalently, a dose of fifty percent. No specific review frequency was found so CSU requires program review every three years. Periodically re-evaluate employee exposures.

The Hearing Conservation Program was reviewed within three years.

The Hearing Conservation Program was not reviewed within three years.

The Hearing Conservation Program is not applicable to my campus.

Hot Work (Cutting/Welding)

See https://up.codes/viewer/california/ca-fire-code-2016/chapter/35/welding-and-other-hot-work#35. A permitted program, carried out by approved facilities-designated personnel, allowing them to oversee and issue permits for hot work conducted by their personnel or at their facility. The intent is to have trained, on-site, responsible personnel ensure that required hot work safety measures are taken to prevent fires and fire spread. Review every three years.

The Hot Work Program was reviewed within three years.

The Hot Work Program was not reviewed within three years.

The Hot Work Program is not applicable to my campus.

Injury & Illness Prevention Program

See https://www.dir.ca.gov/Title8/3203.html. Every employer shall establish, implement and maintain an effective Injury and Illness Prevention Program...in writing. Review every three years unless a change requires it sooner.

The IIPP was reviewed within three years.

The IIPP was not reviewed within three years.

Laboratory Safety - Chemical Hygiene Plan

See https://www.dir.ca.gov/Title8/5191.html. ...review and evaluate the effectiveness of the Chemical Hygiene Plan at least annually and update it as necessary

The Chemical Hygiene Plan (CHP) was reviewed and/or updated within a year.

The CHP was not reviewed and/or updated within a year.

The CHP does not apply to my campus.

Lockout/Tagout (Control of Hazardous Energy)

See https://www.dir.ca.gov/Title8/3314.html. The employer shall conduct a periodic inspection of the energy control procedure(s) at least annually to evaluate their continued effectiveness and determine necessity for updating the written procedure(s)...performed by an authorized employee or person other than the one(s) utilizing the hazardous energy control procedures being inspected...shall certify that the periodic inspections.

The LOTO program was reviewed within a year.

The LOTO program was not reviewed within a year.

The LOTO program does not apply to my campus.

Medical Surveillance

See https://www.dir.ca.gov/dosh/coronavirus/Temp-Delay-Mandated-Exams.pdf. 28 Cal/OSHA standards require employers to offer their employees medical surveillance examinations and other medical services on a specified schedule, when employees may be exposed to certain workplace hazards above an Action Level (AL). Medical Surviellance requirements are identified within each specific standard where it is relevant. If a campus uses a medical surveillance program, review annually.

The Medical Surveillance Program was reviewed within a year.

The Medical Surveillance Program was not reviewed within a year.

The Medical Surveillance Program does not apply to my campus.

Personal Protective Equipment (PPE)

See https://www.dir.ca.gov/Title8/3380.html. ...assess the workplace to determine if hazards are present, or are likely to be present, which necessitate the use of PPE...verify that the required workplace hazard assessment has been performed through a written certification that identifies...

PPE Hazard Assessments have been recertified within three years.

PPE Hazard Assessments have not been recertified within three years.

Powered Industrial Truck

See https://www.dir.ca.gov/Title8/sb7g4a25.html.

The Powered Industrial Truck (PIT) program was reviewed within three years.

The PIT program was not reviewed within three years.

The PIT program does not apply to my campus.

Radiation (Ionizing) Safety

See https://www.cdph.ca.gov/Programs/CEH/DRSEM/CDPH%20Document%20Library/RHB/X-ray/RHB-Guide-RadProtectionProgram.pdf. In California, all radiation sources, either radiation (X-ray) machines or radioactive material, are subject to State laws and regulations...Each registrant is required to develop, document, and implement a radiation protection program commensurate with the scope and extent of use...maintain all records of the Radiation Protection Program, including annual program audits and program content review. Review annually.

The Radiation program was reviewed within a year.

The Radiation program was not reviewed within a year.

The Radiation program does not apply to my campus.

Respiratory Protection Program

See https://www.dir.ca.gov/Title8/5144.html. ...develop and implement a written respiratory protection program with required worksite-specific procedures…"program shall be updated as necessary"…CSU will update every three years.

The Respiratory Protection Program (RPP) was reviewed within three years.

The RPP was not reviewed within three years.

The RPP does not apply to my campus.

Occupational Safety Lagging Indicators

The three year incidence rate (IR), lost time incidence rate (LTIR), and occupational fatalities from the most recent years, and the experience modification rates (X-Mod) will be used as lagging metrics. Sedgewick and Alliant provide the information to SRM, so there is no need to enter the data.

We use the three most recent years for IR and LTIR to minimize annual fluctuation. The Formula is: [(sum of recordable incidents from three most recent years * 200,000) / sum of payroll hours worked from the same three years].

Experience Modification (X-Mod) is a measure of Campus claims experience compared to the Systemwide average. An X-Mod below 100% means your campus claims history is better than the Systemwide average. An X-Mod above 100% means your campus claims history is higher than the Systemwide average. By definition, the Systemwide average is 100%.

Experience Rating is a method of adjusting program contributions based on past claims experience. This is achieved through the addition of an Experience Modification Factor (X-Mod).

See the injuries and fatalities spreadsheet at this link (will be updated when new data is available) - https://csyou.calstate.edu/groups/risk/wercs/EHS/EHS-Directors/Shared%20Documents/Annual%20Reports%20from%20Campuses/2022%20EHS%20Annual%20Report/X-Mod%20Rates%20for%20Campuses%208-2022.xlsx?d=wacb3144f2ee14daaae87849e972348d1.

See the X-MOD spreadsheet at this link - https://csyou.calstate.edu/groups/risk/wercs/EHS/EHS-Directors/Shared%20Documents/Annual%20Reports%20from%20Campuses/2022%20EHS%20Annual%20Report/X-Mod%20Rates%20for%20Campuses%208-2022.xlsx?d=wacb3144f2ee14daaae87849e972348d1.

Environmental Compliance Metrics

• Cost and Amount (per quarter) • Hazardous Waste • Universal Waste • Medical Waste • Radioactive Waste • Total Regulated Waste • Environmental releases • Include question whether campus is a VSQG, SQG, LQG, based on EPA regulations

Hazardous Waste

List cost (first line) and Amount (i.e. lbs. of waste) - second line)

Universal Waste

List cost (first line) and Amount (second line)

Regulated Medical Waste

List cost (first line) and Amount (second line)

Radioactive Waste

List cost (first line) and Amount (second line)

Total Regulated Waste

List cost (first line) and Amount (second line)

Hazardous Waste Generator Type

Select

Environmental Releases

Please list the environmental releases that required reporting to a regulatory agency.

Environmental Program Reviews

• SPCC Plan – include wells, etc. • SB-14 / Waste Minimization • HMBP • Medical Waste Management Plan

Waste Minimization

SB-14 - https://dtsc.ca.gov/sb14/sb14-introduction-and-overview/ Applies to facilities that generate 12,000 kg (25,000 pounds) hazardous waste. Facilities required to file must prepare three Hazardous Waste Source Reduction documents: - Source Reduction Evaluation Review and Plan - Performance Report - Summary Progress Report (SPR) Update every 4 years.

Campuses may be able to exempt large quantities of their waste streams so they fall below the 12,000KG SB-14 trigger for submitting a formal Source Reduction Plan to the regulators. See Chico State Guidance in this SharePoint file:

https://csyou.calstate.edu/groups/risk/wercs/EHS/environmental/_layouts/15/guestaccess.aspx?guestaccesstoken=zd6mMKOTz%2fOdNwJIfhNJOEaAR0U9Vf%2b8Fm3YRC16uA4%3d&folderid=2_1ee877117402948f8a6029339c642e5ca&rev=1

Waste Minimization Plan was reviewed within 4 years.

Waste Minimization Plan was not reviewed within 4 years.

SB-14 is not applicable for my campus.

Stormwater Pollution Prevention Plan*

https://www.waterboards.ca.gov/water_issues/programs/stormwater/municipal.html https://www.waterboards.ca.gov/water_issues/programs/stormwater/docs/phsii2012_5th/order_final.pdf Required for facilities required to be covered under Statewide General Permit for Stormwater Discharges From Small Municipal Separate Storm Sewer Systems (MS4s)

If a Permittee has an existing or equivalent document such as Hazardous Materials Business Plan or Spill Prevention Plan, the Permittee may not be required to develop a SWPPP if that document includes the necessary information required within a SWPPP. See guidance on this from CSUDH in this SharePoint document: https://csyou.calstate.edu/groups/risk/wercs/EHS/environmental/Shared%20Documents/Storm%20Water%20Pollution%20Prevention/Guidance%20to%20reference%20in%20EHS%20Annual%20Report%20Systemwide/MS4-Section-F-Provisions_SWPPP-Language.pdf

Stormwater Pollution Prevention Plan has been developed and implemented.

Stormwater Pollution Prevention Plan has not been developed and implemented.

Not applicable

Hazardous Materials Business Plan

Hazardous Materials Release Response Plans and Inventory HSC, Sections 25500 - 25547.8 https://leginfo.legislature.ca.gov/faces/codes_displaySection.xhtml?lawCode=HSC&sectionNum=25500 Required for any facility that stores or uses hazardous materials in excess of 500 pounds for a solid, 55 gallons for a liquid, or 200 cubic feet for a gas, or for any facility required to report an EHS in excess of its TPQ or 500 pounds, whichever is less. Report due every year.

Hazardous Materials Business Plan was updated and submitted within the last year.

Hazardous Materials Business Plan was not updated and submitted within the last year.

Not applicable

Medical Waste Management Plan

Medical Waste Management Act, HSC, Sections 117600-118360. https://www.cdph.ca.gov/Programs/CEH/DRSEM/CDPH%20Document%20Library/EMB/MedicalWaste/MedicalWasteManagementAct.pdf Generators of medical waste are required to file with the enforcement agency a medical waste management plan. Review frequency is not applicable.

Medical Waste Management Plan has been filed with the enforcement agency.

Medical Waste Management Plan is required but has not been filed with the enforcement agency.

Not applicable to my campus

SPCC

40 CFR, Part 112 | California APSA | HSC, Chapter 6.67, Sections 25270-25270.13 Required for bulk oil storage exceeding 1,320 gallons. Review every 5 years or whenever there is a technical change at the facility.

SPCC was reviewed within 5 years.

SPCC was not reviewed within 5 years.

SPCC does not apply to my campus.

Good Practices

This section collects information on how campuses handle key processes and how they would derive KPI's for those processes. These areas need further process development and consistency before our systems can provide accurate enough data to document and report on KPI's. The CSU EHS Affinity Group can collectively review information provided in this section, align with each other, and eventually develop accurate KPI's for reporting and goal setting purposes.

HazWaste Utilities Budget

This question is being asked because some campuses have a line item in their utility budget for HazWaste and some campus EHS departments did not know about this. If an EHS Director becomes aware of this, they have the opportunity to become involved with it.

Yes, the HazWaste budget is part of the utilities budget.

No, the HazWaste budget is not part of the utilities budget.

I am not sure about HazWaste budget.

RSS Hazard Assessments Completed

How do you ensure hazard assessments are completed for all labs with relevant chemical, biological, radiological, or physical hazards? What do you recommend as a Systemwide process or metric for ensuring this?

RSS Inspections Completed

How do you ensure lab inspections are completed annually for all areas where hazard assessments indicate presence of chemical hazards? What do you recommend as a Systemwide process or metric for assuring this?

Student Training Needs Assessment

How do you ensure students are assigned and complete lab safety training? What do you recommend as a Systemwide process or metric to track this? Is there a need to demarcate training between instructional labs and research labs (or any other form of lab)?

Employee EHS Training Needs Assessment

How do you ensure your employees are assigned the proper EHS training (focusing at this point on IIPP, HazCom, HazWaste, and Lab Safety)? This could be called a training needs assessment. What do you recommend for a Systemwide Process or metric to ensure proper training is assigned?

Fire Extinguishers Method

Please briefly describe how your campus manages fire extinguisher inspections. What do you recommend as a metric for this?

Describe HVAC Systems Inspections Documentation Method

Please describe how you document and ensure the HVAC inspections are occurring.

Asbestos O&M Program

Does your campus personnel complete any of the following O&M tasks (i.e., not contracted out)? Note-Completion of some of these tasks by campus personnel may require specialized training, medical surveillance, and exposure monitoring.

Select or enter value

Date Collected

Additional Information - Feel free to add any additional information.

You may want to briefly mention key accomplishments or programs not listed.

Compliance Action Plans*

Identify reasons for any delays in the timeliness of inspections of safeguards, engineering controls and ventilation systems and provide action plans to achieve compliance.

File Upload

Insert org chart of where EHS falls within campus operations. Insert org chart of EHS department.

Drag and drop files here or

Send me a copy of my responses

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