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Comprehensive Standard 3.11.2

The institution takes reasonable steps to provide a healthy, safe, and secure environment for all members of the campus community. (Institutional environment)


√ CompliantNon-Compliant

Narrative

The University of Texas Medical Branch at Galveston (UTMB), in accordance with University of Texas System policies, has developed an emergency management framework for response to threats, internal and external. This framework addresses preparedness, mitigation, response, and recovery and guides all personnel in managing events safely and assuring rapid recovery to normal operating conditions.

In addition, UTMB takes all reasonable steps to assure that students, employees, patients, and visitors have a healthy, safe, and secure environment on an on-going basis. Policies concerning these institutional issues are located online in the Institutional Handbook of Operating Procedures (IHOP) and are included as part of the mandatory safety training for employees, students, contract workers, and volunteers.

Departments responsible for health, safety, and environmental security are UTMB Police, Environmental Health and Safety (includes Biological and Chemical Safety, Environmental Protection Management, Occupational Safety and Fire Prevention, and Radiation Safety), Supply Chain Management, and Fleet Services. UTMB Police is a stand-alone department. All the others report up through the Vice President, Business Operations and Facilities.

Emergency Management.
In accordance with the University of Texas System Policy 172, Texas Education Code Section 51.218, and the Joint Commission Emergency Management Standards, UTMB maintains an Emergency Management program that addresses preparedness, mitigation, response, and recovery. The UTMB Emergency Management program is reviewed annually by the Emergency Management and Life Safety Committee and the Institutional Safety and Security Executive Committee (1). State law requires that the emergency management program be audited at least every three years with the results being reported to the UT Board of Regents and the Governor’s Office. UTMB completed its audit as well as the JACHO Survey of Emergency Management standards in 2012 (2).

UTMB is part of the Galveston County Emergency Response Collaborative. In order to notify students, faculty, and staff of unsafe conditions, UTMB has a mass notification capability. Students are automatically enrolled in the mass notification at the beginning of the semester, but they may elect to not participate in the program by submitting a written request. If the request is approved, it must be renewed each year or the student will be automatically re-enrolled in the notification system. The UTMB Emergency Operations website includes annual hurricane preparedness, institutional planning, academic planning, research planning, bioterrorism/disease readiness, communications, reports and analysis, community resources, and personal/family checklists and preparedness (3).

The UTMB Emergency Management Plan (4) is institutional, involving the hospitals, business and administrative offices, the schools, and institutes. Developed collaboratively by representatives from each of these areas, this information is reviewed annually, revised as necessary, and approved by the President’s Council. Business Operations and Facilities (BOF) has the responsibility of assessing building vulnerabilities University-wide and assuring that each building or renovation project is in compliance with current basis for design specifications and the Hurricane Mitigation Study recommendations adopted in January, 2009. BOF is also responsible for coordinating disaster response and recovery with respect to repairs and services or department relocations within UTMB facilities (5).

Institutional Handbook of Operating Procedures (IHOP)
IHOP policies that focus on the health of the University community include:
• Reproductive/Fertility Hazards in the Workplace (6)
• Vaccination of Healthcare Workers to Protect Patients from Vaccine Preventable Infections (7)
• Policy and Guidelines on AIDS, HIV, and Hepatitis B (8)
• Tobacco Free Policy (9)

Programs and services are in place to assist individuals in conforming to the above policies. For example, a free smoking cessation program, Commit to Quit, assists smokers in breaking nicotine addiction (10), and designated health care workers are screened for tuberculosis at the time of employment, with annual repeat screening for some employees based on their job category (11).

Safety-related policies in IHOP are organized under Section 8, Health, Safety and Security, and include:
• Workplace Violence (12)
• Fire Alarm and Incident Response Policy (13)
• Removal/Disposal of Hazardous Waste (14)
• Safety Training (15)
• Decorations Safety Policy (16)
• Portable Heating Devices (17)
• Threatening Situations (18)
• Possession of Weapons (19)

Most safety policies are the responsibility of the UTMB Police Department and will be discussed in greater detail below under “UTMB Police.”

IHOP policies related to a secure environment include:
• Identification Badges/Smart Cards (20)
• Staffing During Adverse Conditions (21)

Departments Responsible for Health, Safety, and Environmental Security
Policies related to environmental security were tested in 2005 during Hurricane Rita, in 2008 during Hurricane Ike, and during the annual training/exercises. Changes have been made as a result of these experiences. Identification badges are gradually being replaced with smart cards to more efficiently maintain security and control access to specific buildings and areas (22). A Campus Security Report covering both personal and environmental safety was released in September 2012 and is available on the institutional website (23).

Environmental Health and Safety Department (EHS)
EHS is a division of Business Operations and Facilities and is responsible for, but not limited to:
• Providing staff support to safety committees;
• Assisting in the formulation of safety policies;
• Providing safety-related technical services;
• Assisting in the development and implementation of safety programs;
• Consulting with faculty, staff and students about safety issues;
• Didactic and hands-on laboratory safety training (24).

EHS provides advice, assistance and technical services for the development and implementation of all environmental health and safety programs. The safety and environmental program areas of EHS, each of which is discussed in some depth below, are: Biological and Chemical Safety, Environmental Protection Management, Fleet Services, Occupational Safety and Fire Prevention, and Radiation Safety.

Biological and Chemical Safety. The Biological and Chemical Safety Program (B&C) provides the following services (25):
• Certifying chemical fume hoods, biological safety cabinets, and laminar flow cabinets;
• Administering all aspects of the Asbestos Management Program;
• Monitoring for exposure to toxic chemicals;
• Consulting on safety issues regarding the use of chemical and biological agents;
• Consulting regarding spills of hazardous materials;
• Overseeing packaging, labeling, and documentation for shipment of chemicals and biological agents from UTMB;
• Providing assistance with Hazard Communication Act and Material Safety Data Sheet interpretation;
• Conducting respirator fit testing;
• Consulting on medical waste issues;
• Developing and delivering specialized safety training relevant to biological and chemical safety;
• Developing specifications and guidelines for purchase and installation of safety equipment;
• Reviewing renovation and construction plans;
• Consulting on indoor air quality and other industrial hygiene issues;
• Inspecting/auditing research and clinical laboratory areas for compliance with federal, state, and local regulation;
• Offering Research Laboratory Biosafety Training Program for the high containment laboratories as well as training for all BSL2 labs at UTMB;
• Assisting faculty in preparing documentation for review and approval by the Chemical Safety Committee and the Institutional Biosafety Committee, both of which are discussed in more depth below.

The U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, and the U.S. Department of Agriculture, Animal Plant Health Inspection Service, National Select Agent Program provide a certificate of registration to UTMB that authorizes the University to possess, use and transfer select agents and toxins as specified in the application (26).

The UTMB Chemical Safety Committee (CSC) recommends policies and monitors programs for the control and safe use of hazardous chemicals, including those that are carcinogenic, toxic, reactive, corrosive, and flammable (27). This committee meets bi-monthly and shares committee members with the following standing committees: Radiation Safety Committee, Institutional Animal Care and Use Committee, and the Institutional Biosafety Committee. The CSC is responsible for:
• Formulating policies governing chemical safety;
• Reviewing and approving Highly Hazardous Chemical Safety Plans, including a risk analysis;
• Reviewing and approving safety plans for the Environmental Toxicology Laboratory; • Monitoring the effectiveness of chemical safety programs;
• Recommending actions to correct safety deficiencies.

The Institutional Biosafety Committee (IBC) recommends policies and monitors programs for the control and safe use of hazardous biological agents, including non-exempt recombinant DNA, oncogenic viruses, and infectious agents (28). The IBC is directly linked into the University Employee Health and EHS office to ensure that appropriate health assessments and immunizations have been received and documented, as well as ensure that biosafety issues are addressed. This committee meets monthly and membership includes at least two community representatives. The IBC also shares committee members with the following standing committees: Radiation Safety Committee, Institutional Animal Care and Use Committee, and the Chemical Safety Committee. Members are appointed by the Executive Vice Chancellor of Health Affairs through The University of Texas System. This committee is registered with the NIH Office of Biotechnology Activities. The IBC is responsible for:
• Formulating policies governing biosafety;
• Reviewing and approving Notification of Use for Biological Agents and rDNA/RNA which includes a risk and dual use analysis;
• Monitoring the effectiveness of biosafety programs;
• Recommending actions to correct safety deficiencies.

Environmental Protection Management. The Environmental Protection Management (EPM) program uses a team-based approach to provide day-to-day environmental management activities throughout the UTMB community (29). Routine program services include:
• Managing the Hazardous Waste Disposal Program, including implementing federal, state, and local regulations pertaining to the handling, storage, transportation, recordkeeping, and disposal of hazardous waste;
• Providing technical assistance and training to the University community on identifying and disposing of waste;
• Providing assistance to personnel working with processes that generate hazardous chemicals or wastes in applying source reduction and waste minimization measures, e.g., silver reclamation for film developing, solvent distillation, and mercury reduction;
• Inspecting or auditing the University for environmental compliance;
• Developing and managing air and water pollution control strategies, plans, and programs;
• Providing hazardous material emergency spill response.

Environmental protection programs include air, water, and land matrices. UTMB received a Title V Operating Permit in 2005 that provides a compilation of federal and state air requirements to minimize air pollutants. This permit outlines regulations for monitoring and recordkeeping requirements for University utilities (i.e., boilers, emergency generators, incinerator and autoclave processes, fuel tanks, and lithographic printers).

In 2003, the Texas Commission on Environmental Quality (TCEQ) introduced Phase II storm water regulations for discharges of storm water runoff from construction sites. Since that time, UTMB has maintained operational control of construction project plans and specifications, including the ability to make modifications as required. The contractors on UTMB sites, when disturbing earth, are responsible for the day-to-day operational control of activities necessary to ensure compliance with a Storm Water Pollution Prevention Plan (SWPPP) for their respective sites site and are required to obtain permit coverage (30).

EPM implemented an Environmental Management System in 2005. This system tracks the regulatory requirements through a calendar/email notification process for assignment of environmental reporting and procedural responsibilities. The computer-based program is used as an information resource to provide environmental aspect references, clear definitions for staff roles and responsibilities, and reporting functions. This team approach is used to ensure environmental compliance initiatives and programs are communicated University-wide.

The Texas Commission on Environmental Quality (TCEQ) staff audited UTMB’s environmental compliance programs in 2006 in order to assess performance and identify improvement opportunities. TCEQ recommended UTMB to the Environmental Protection Agency (EPA) as a National Environmental Performance Track (NEPT) program, a program for recognizing top environmental performers (31).

Fleet Services. UTMB has had a Fleet Management Program in place for all motorized vehicles used by University departments since 1989. The program includes coordination of all vehicle purchasing and disposal, vehicle insurance, preventive and routine maintenance, regulatory reporting and tracking, fuel management, and driver safety training. The University currently has 184 vehicles of various types in this program. They range from UTMB-based small utility vehicles used by our maintenance staff to refrigerated box trucks for the movement of animal resources. The program is in compliance with UT System policies regarding automobile insurance and general requirements for the use of vehicles (32) as reflected in the UTMB Handbook of Operating Procedures policies concerning vehicle use (33).

The Fleet Management “Driver Safety Program” requires that all UTMB vehicle operators pass the National Safety Council’s Defensive Drivers Course every two years. This program, www.idrivesafely.com, is offered on at the University on a monthly basis (34). The program includes measures relating to the qualification, training and supervision of employees and others who drive University vehicles, the establishment of safe practices and rules, planned inspections and maintenance of vehicles, and the reporting, investigation, and review of accidents.

Occupational Safety and Fire Prevention. Occupational Safety and Fire Prevention (OS&FP) consults with various departments to implement safety policies and procedures to ensure a safe environment for UTMB employees, students, and visitors (35). OS&FP is intimately involved with the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) accreditation process for the University Hospital System, including representatives on many of the required inspection teams and committees. In addition, OS&FP is responsible for the inspection requirements of all UTMB Fire/Life Safety Systems that must comply with National Fire Codes, State Fire Marshal (SFMO) requirements and JCAHO requirements. Some items OS&FP is responsible for include but are not limited to:
• Conducting general safety and life safety inspections, including annual building life safety surveys, accident and near miss reports, safety shows, storage, and exit/egress;
• Testing and inspection of all fire alarm systems, sprinkler systems, suppression systems, and portable fire extinguishers;
• Conducting UTMB-wide fire drills;
• Assisting in the development and evaluation of fire protection methods;
• Conducting hands-on fire safety training classes;
• Developing evacuation, safety management, and fire department response plans;
• Investigating of UTMB accident reports;
• Reviewing construction project design, development, plans/submittal reviews, site visit, test/inspections (pre-test, final acceptance, overhead/cover-up, commissioning, follow-up), code interpretations, Authority Having Jurisdiction (AHJ) approvals and SFMO correspondences.

Radiation Safety. A license to possess and use radioactive materials has been issued to UTMB by the Texas Department of State Health Services (TDSHS). The license is called “Specific License of Broad Scope” because it permits the flexibility that is required for patient care and research in a dynamic medical center (36). In addition, Certificates of X-ray Registrations, Mammography and Lasers have also been issued to UTMB by TDSHS. The conditions on the License and Registrations require UTMB to maintain a well-managed and documented program to ensure that sources of radiation are used safely. The UTMB Radiation Safety Manual was updated in 2012 (37).

The Radiation Safety Committee (RSC) is responsible for ensuring that ionizing and non-ionizing radiation are used safely and in accordance with state and federal regulations (38). RSC is responsible for:
• Formulating general policy governing the use of ionizing and non-ionizing radiation;
• Reviewing and approving all requests for the use of ionizing and non-ionizing radiation at UTMB;
• Determining that all individuals authorized to use radiation have sufficient training and experience to enable them to perform their duties safely;
• Establishing a program to ensure that all individuals whose duties may require them to work in the vicinity of radiation are properly instructed about all appropriate health and safety matters.

The RSC meets at least quarterly. Members include a representative of the administration, the Radiation Safety Officer, physicians with expertise in the use of radioactive materials and radiation producing machines for diagnosis and therapy, and individuals with expertise in the use of radioactive materials.

The Radiation Safety Program provides the following services:
• Assisting in the development of general policies for control of radiation;
• Collecting and disseminating information relative to radiation protection;
• Evaluating equipment and physical facilities;
• Evaluating operational techniques and procedures;
• Providing radiation safety training;
• Conducting an audit program to assure the laboratory facilities and procedures are in accordance with UTMB policies and Texas Administrative Codes (TAC) for Radiation;
• Providing advice on decontamination of facilities and equipment following spills or prior to remodeling or modification of facilities;
• Responding to emergencies and investigates accidental exposures;
• Aiding in the completion of the “Application for Permit to Use Radioactive Material,” “Application for Laser User Permit,” and “Application for Laser Registration”;
• Conducting a monitoring program for laboratory contamination;
• Conducting bioassay program for internal deposition of radionuclides;
• Issuing personnel dosimetry devices and reviews reports;
• Receiving and inspecting packages containing radioactive materials;
• Maintaining and updating an inventory of radioactive materials and radiation producing machines;
• Processing outgoing shipments of radioactive materials in accordance with federal and state regulations;
• Calibrating portable radiation survey instruments;
• Maintaining records necessary to comply with TAC for Radiation.

The Texas Department of State Health Services has completed the following audits:
• UTMB Radioactive Material Use License L01299 -003 on March 31, 2013 and found the radiation safety program in compliance (39).
• UTMB Certificate of X-Ray Registration R00216-000 on December 17, 2012. No violations were noted (40).
• UTMB Certificate of X-ray Registration R00216-006 on December 19, 2012. No violations were noted (41).
• UTMB Certificate of X-ray registration R00216-008 on July 26, 2012. No violations noted (42).
• UTMB Certificate of X-ray Registration R00216-009 (Therapy) on February 27, 2013. No violations noted (40).
• UTMB Certificate of Mammography Systems M00525 on January 28, 2013. No violations were found during the inspection. A Certificate of Inspection was issued to UTMB (44).
• UTMB Certificate of Mammography Systems M001143 on April 10, 2012. No violations were found during the inspection. A Certificate of Inspection was issued to UTMB (45).
• UTMB Certificate of Mammography Systems, M00144 on April 10, 2012. No violations were found during the inspection. A Certificate of Inspection was issued to UTMB (expired) (46).

UTMB Police
The UTMB Police Department is a full-service criminal justice agency, providing law enforcement services 24 hours a day, seven days a week, 365 days a year. This includes full arrest authority. UTMB police officers are commissioned by the UT System Board of Regents and licensed by the Texas Commission on Law Enforcement Officer Standards and Education, after they have successfully completed the state-mandated training curriculum and achieved a passing score on the State of Texas licensing examination. Officers receive 40 hours of state mandated in-service training every two years (47).

The department provides a fully staffed police communications center to dispatch assistance to the University community and to provide around the clock monitoring of a sophisticated, computer-based, electronic network of intrusion detection and duress alarms. This center maintains contact with area police and emergency agencies through two-way radio communication so that assistance and support from these departments can be obtained immediately when needed. UTMB also coordinates responses to crimes in adjoining jurisdictions when requested to do so. The department utilizes a bicycle patrol to enhance community relations and patrol effectiveness. The bicycle patrol operates in highly populated areas of the institution.

Crime-related reports and information, including incidents at recognized off-UTMB student organization housing facilities, are routinely exchanged. The UTMB Police Department coordinates the timely release of information about serious crimes that may threaten the safety of students and employees through the Office of University Advancement. When necessary for public safety, warnings are posted on the UTMB intranet on the home page and are circulated by e-mail (48). In addition, an active shooter training exercise has been held on campus in cooperating with the Galveston Police Department, the Port of Galveston Police Department, The Galveston County Sheriff’s Office, and the University of Houston-Clear Lake Police (49).

The crime prevention program (50) currently in place at UTMB consists of the following services:

Escort Programs: The UTMB Police Department provides escort service (“Safety Watch”) for persons walking around UTMB after dark. Emergency call boxes are utilized and enhance safety across the University.

Crime Prevention Presentations: Crime prevention presentations are held for employees, commuter students, students with disabilities, international students, student government, faculty and staff organizations, specific University departments, and recognized student organizations. Crime prevention presentations are included in each scheduled student orientation and at other on-UTMB student residences, such as fraternity and sorority houses; and at off-UTMB student organization facilities. Crime prevention materials are distributed, and articles promoting crime prevention are published in the student newspaper/newsletters (Omni), in the employee newspaper (Impact). As part of its preparedness effort, UTMB conducts training in workplace violence and infant abduction that is available to students, faculty, and staff (51).

Architectural Design: Technical and crime prevention specialists of the UTMB Police Department have significant input into the design of the physical and electronic security systems of all new and renovated University facilities. Card key access is utilized to control access to university facilities. All 24/7 student study areas require a current student ID card to gain access.

Security Surveys: Comprehensive security surveys or audits are made for a number of University facilities throughout the year. Surveys of exterior lighting and of exterior doors and grounds are conducted by patrol officers and guards.

Operational Identification: Operation Identification, the engraving of owner-recognized numbers on items of value, is strongly promoted for UTMB students and employees.

Sources
1. Business Operations and Facilities
http://www.utmb.edu/bof/

2. UTMB Emergency Operations Plan (revised 5-4-2011)
PDF accessed through http://www.utmb.edu/emergency_plan/

3. Institutional Handbook of Operating Procedures, Section 8, Policy 8.1.13, Reproductive/Fertility Hazards in the Workplace
http://www.utmb.edu/policies_and_procedures/IHOP/Health_Safety_and_Security/IHOP%20-%2008.01.13%20-%20Reproductive%20or%20Fertility%20Hazards%20in%20the%20Work%20Place.pdf

4. Institutional Handbook of Operating Procedures, Section 3, Policy 3.7.7, Vaccination of Healthcare Workers to Protect Patients from Vaccine Preventable Infections.
http://www.utmb.edu/policies_and_procedures/IHOP/Employee/Health_and_Wellness/IHOP%20-%2003.07.07%20-%20Vaccination%20of%20Healthcare%20Workers%20to%20Protect%20Patients%20from%20Vaccine%20%20Preventable%20Infections.pdf

5. Institutional Handbook of Operating Procedures, Section 8, Policy 8.1.1, Policy and Guidelines on AIDS, HIV, and Hepatitis B
http://www.utmb.edu/policies_and_procedures/IHOP/Health_Safety_and_Security/IHOP%20-%2008.01.01%20-%20Policy%20and%20Guidelines%20on%20AIDS,%20HIV,%20and%20Hepatitis%20B.pdf

6. Institutional Handbook of Operating Procedures, Section 3, Policy 3.7.6, Tobacco Free Policy
http://www.utmb.edu/policies_and_procedures/IHOP/Employee/Health_and_Wellness/IHOP%20-%2003.07.06%20-%20Tobacco%20Free%20Policy.pdf

7. Commit to Quit Program
http://hr.utmb.edu/ehp/commit_to_quit.aspx

8. Institutional Handbook of Operating Procedures, Section 8, Policy 8.1.2, Tuberculosis Surveillance Program for Healthcare Workers
http://www.utmb.edu/policies_and_procedures/IHOP/Health_Safety_and_Security/IHOP%20-%2008.01.02%20-%20Tuberculosis%20Surveillance%20Program%20for%20Healthcare%20Workers.pdf

9. Institutional Handbook of Operating Procedures, Section 8, Policy 8.1.4, Workplace Violence
http://www.utmb.edu/policies_and_procedures/IHOP/Health_Safety_and_Security/IHOP%20-%2008.01.04%20-%20Workplace%20Violence.pdf

10. Institutional Handbook of Operating Procedures, Section 8, Policy 8.1.5, Fire Alarm and Incidence Response Policy
http://www.utmb.edu/policies_and_procedures/IHOP/Health_Safety_and_Security/IHOP%20-%2008.01.05%20-%20Fire%20Alarm%20and%20Incident%20Response%20Policy.pdf

11. Institutional Handbook of Operating Procedures, Section 8, Policy 8.1.6, Removal/ Disposal of Hazardous Waste
http://www.utmb.edu/policies_and_procedures/IHOP/Health_Safety_and_Security/IHOP%20-%2008.01.06%20-%20Removal%20or%20Disposal%20of%20Hazardous%20Waste.pdf

12. Institutional Handbook of Operating Procedures, Section 8, Policy 8.1.12, Safety Training
http://www.utmb.edu/policies_and_procedures/IHOP/Health_Safety_and_Security/IHOP%20-%2008.01.12%20-%20Safety%20Training.pdf

13. Institutional Handbook of Operating Procedures, Section 8, Policy 8.1.14, Decorations Safety Policy
http://www.utmb.edu/policies_and_procedures/IHOP/Health_Safety_and_Security/IHOP%20-%2008.01.14%20Decorations%20Safety%20Policy.pdf

14. Institutional Handbook of Operating Procedures, Section 8, Policy 8.1.19, Portable Heating Devices
http://www.utmb.edu/policies_and_procedures/IHOP/Health_Safety_and_Security/IHOP%20-%2008.01.19%20Portable%20Heating%20Devices.pdf

15. Institutional Handbook of Operating Procedures, Section 8, Policy 8.2.1, Threatening Situations
http://www.utmb.edu/policies_and_procedures/IHOP/Health_Safety_and_Security/IHOP%20-%2008.02.01%20-%20Threatening%20Situations.pdf

16. Institutional Handbook of Operating Procedures, Section 8, Policy 8.2.4, Possession of Weapons
http://www.utmb.edu/policies_and_procedures/IHOP/Health_Safety_and_Security/IHOP%20-%2008.02.04%20-%20Possession%20of%20Weapons.pdf

17. Institutional Handbook of Operating Procedures, Section 8, Policy 8.2.3, Identification Badges/Smart Cards
http://www.utmb.edu/policies_and_procedures/IHOP/Health_Safety_and_Security/IHOP%20-%2008.02.03%20-%20Identification%20Badges%20or%20Smart%20Cards.pdf

18. Institutional Handbook of Operating Procedures, Section 3, Policy 3.1.1, Staffing During Adverse Conditions
http://www.utmb.edu/policies_and_procedures/IHOP/Employee/General/IHOP%20-%2003.01.01%20-%20Staffing%20During%20Adverse%20Conditions.pdf

19. Identification Badges/Smart Cards/Keys
http://www.utmb.edu/police/BadgesandKeys.asp

20. 2012 Annual Security Report
http://www.utmb.edu/securityreport/

21. Environmental Health and Safety Department
See http://www.utmb.edu/bof/ for list of EHS Services

22. Biological and Chemical Safety Program
http://www.utmb.edu/bof/BC/Training/section1/4-0BioChemSafetyProgram.asp

23. Regulations Concerning Registration to Possess, Use, and Transfer Select Agents and Toxins, National Select Agent Program 42 CFR 73, specifically Sections 73.9, Responsible Official; 73.10, Restrictive Access; 73.11, Security; 73.12, Biosafety; 73.14, Incidence Response; 73.15, Training; 73.16, Transfers; and 73.17, Records.
http://www.selectagents.gov/resources/42_CFR_part_73_Final-English.pdf
[This is considered a security sensitive document and is not provided to non-select agent entities. So Kim and Lynda have substituted the reference for the CDC select agent program which is the federal regulations where UTMB is registered.]

24. Chemical Safety Committee
http://www.utmb.edu/bof/BC/Training/section8/1-Roles%20Responsibilities%20for%20Chem%20Safety.html

25. Institutional Biosafety Committee
http://www.utmb.edu/GNL/safety/committee.shtml

26. Environmental Protection Management
http://www.utmb.edu/bof/epm/default.asp
http://www.utmb.edu/bof/BC/Training/section1/6-EPM.asp

27. Storm Water Pollution Prevention Program
http://www.utmb.edu/bof/EPM/epmstormwater.asp

28. National Environmental Performance Track (NEPT) Recognition
http://www.epa.gov/performancetrack/downloads/PT_ProgRprt_2009_web.pdf

29. University of Texas System Administration Policy Library, Policy No. UTS157, Automobile Insurance Coverage for Officers and Employees and General Requirements for the Use of Vehicles
http://www.utsystem.edu/bor/procedures/policy/policies/uts157.pdf

30. Institutional Handbook of Operating Procedures, Section 8, Policy 8.1.15, General Requirements for Use of Vehicles
http://www.utmb.edu/policies_and_procedures/IHOP/Health_Safety_and_Security/IHOP%20-%2008.01.15%20-%20General%20Requirements%20for%20Use%20of%20Vehicles.pdf

31. National Safety Council’s Defensive Drivers Course
http://www.idrivesafely.com

32. Occupational Safety & Fire Prevention
http://www.utmb.edu/bof/osfp/default.asp

33. Specific License of Broad Scope License to Possess and Use Radioactive Materials
http://www.utmb.edu/bof/rad/images/rsm.pdf (pages 2-1 and 2-2)

34. Radiation Safety Manual
http://www.utmb.edu/bof/rad/images/rsm.pdf

35. Radiation Safety Committee
http://www.utmb.edu/bof/BC/Training/section1/5-RadSafety.asp

36. UTMB Radioactive Material Use License L01299 -003 on March 21, 2013
Hard Copy: Letter from Robert L. Green to Luz Natividad Cheng dated April 24, 2013

37. UTMB Certificate of X-Ray Registration R00216-000 on December 17, 2012.
Hard Copy: Notice of Compliance, Texas Department of State Health Services

38. UTMB Certificate of X-ray Registration R00216-006 on December 19, 2012.
Hard Copy: Notice of Compliance, Texas Department of State Health Services

39. UTMB Certificate of X-ray registration R00216-008 on July 26, 2012.
Hard Copy: Notice of Compliance, Texas Department of State Health Services

40. UTMB Certificate of X-ray Registration R00216-009 (Therapy) on February 27, 2013.
Hard Copy: Notice of Compliance, Texas Department of State Health Services

41. UTMB Certificate of Mammography Systems M000525 on January 28, 2013. No violations were found during the inspection. A Certificate of Inspection was issued to UTMB

42. UTMB Certificate of Mammography Systems M001143 on April 10, 2013.
Hard Copy: Certificate of Inspection, Texas Department of State Health Services

43. UTMB Certificate of Mammography Systems, M001144 on April 10, 2012. (Expired)
Hard Copy: Certificate of Inspection, Texas Department of State Health Services

44. UT System Police
http://www.utsystem.edu/pol/

45. Campus Alert Status
http://intranet.utmb.edu/alert/

46. Active Shooter Training
http://www.utmb.edu/police/OnlineTraining.asp, also
Hard Copy: Exercise—Student Center Deadly Behavior Exercise (Active Shooter)

47. Crime Prevention Programs
http://www.utmb.edu/police/CrimePrevention.asp

48. Evidence of Conducting Annual Crime Prevention Training and Exercises
(hard copy?)

49. Evidence of Student Government Exercises Designed to Address Violence at UTMB
(hard copy)

50. Review of Emergency Management Program by the Environment of Care Committee
(hard copy)

51. Review of Emergency Management Program by the Institutional Safety and Security Executive Committee.
(hard copy)

52. JCAHO Survey of Emergency Management Standards in 2012

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