Compliance Certification Report

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)
√ Compliant
Partially Compliant
Non-Compliant
Narrative:
Institutional Policies
The University of Texas Medical Branch (UTMB) takes all reasonable steps to assure that students, employees, patients, and visitors have a healthy, safe, and secure environment. Policies concerning these institutional issues are located on line in the Institutional Handbook of Operating Procedures (IHOP) (1), and are included as part of the mandatory safety training for employees, students, contract workers, and volunteers (2).

IHOP policies that focus on the health of the campus community include:

  • Reproductive/Fertility Hazards in the Workplace (3)
  • Tuberculosis Surveillance Programs for Healthcare Workers (4)
  • Policy and Guidelines on AIDS, HIV, and Hepatitis B (5)
  • No Smoking Policy (6)
  • 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 addition (7), and designated health care workers are screen for tuberculosis at the time of employment, with annual repeat screening for some employees on the basis of job category.

    Safety-related policies include:
  • Workplace Violence (8)
  • Fire Alarm and Incident Response Policy (9)
  • Removal/Disposal of Hazardous Waste (10)
  • Safety Training (11)
  • Decorations Safety Policy (12)
  • Portable Heating Devices (13)
  • Threatening Situations (14)
  • Possession of Weapons (15)
  • Most safety policies are the responsibility of the UTMB Police Department, whose responsibilities are discussed in greater detail below. The Fleet Management Department, which oversees all of the motorized vehicles owned by UTMB, is also discussed below.

    Policies related to a secure environment include:
  • Identification Badges/Smart Cards (16)
  • Staffing During Adverse Conditions (17)
  • It is the policy of UTMB to provide a framework for response to emergencies, internal or external, naturally occurring or man-made, which will guide all staff in managing the event safely and assuring rapid recovery to normal operating conditions. Policies related to environmental security were tested in 2005 during Hurricane Rita and changes were made as a result of that experience (18). Identification badges are gradually being replaced with smart cards to more efficiently maintain security and control access to specific buildings and areas (19). ). A Campus Security Report covering both personal and environmental safety is released annually by October 1 and is available on the institutional web site (20).

    Office of Environmental Health and Safety
    The UTMB Environmental Health and Safety Program is a division of Facilities Operation and Management (FOAM). Environmental Health and Safety (EHS) 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; and,
  • Consulting with faculty, staff and students about safety issues.
  • 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, Radiation Safety, Environmental Protection Management, and Occupational Safety and Fire Prevention.

    Institutional Safety Committee
    The UTMB Institutional Safety Committee (ISC) recommends policies and monitors programs for the general safety of the campus and reports to executive leadership. This Committee meets monthly and shares committee members with the following standing committees: Environment of Care Committee, Radiation Safety Committee, and the Institutional Biosafety Committee.

    The ISC is responsible for:
  • Formulating policies governing general safety;
  • Reviewing and approving IHOP policies related to general and occupational safety
  • Reviewing and approving Safety Plans for specific functions and programs;
  • Monitoring the effectiveness of safety programs;
  • Recommending actions to correct safety deficiencies;
  • Works closely with the EOC Committee for Healthcare Safety Issues
  • Biological and Chemical Safety
    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. This Committee meets 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 which includes 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;
  • Oversees the activities of EHS.
  • 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. 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 Systems. 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 analysis;
  • Monitoring the effectiveness of biosafety programs;
  • Recommending actions to correct safety deficiencies.
  • The Biological and Chemical Safety Program (B&C) provides the following services:
  • Certifies chemical fume hoods, biological safety cabinets and laminar flow cabinets
  • Administers all aspects of the Asbestos Management Program
  • Provides administrative support for the UTMB, Health and Human Services & United States Department of Agriculture Select Agent Compliance Program
  • Monitor for exposure to toxic chemicals
  • Consults on safety issues regarding the use of chemical and biological agents
  • Consults regarding spills of hazardous materials
  • Oversees packaging, labeling and do
  • cumentation for shipment of chemicals and biological agents off campus
  • Provides assistance with Hazard Communication Act and Material Safety Data Sheet interpretation
  • Conducts respirator fit testing
  • Consults on medical waste issues
  • Develops and delivers specialized safety training relevant to biological and chemical safety
  • Develops specifications & guidelines for purchase and installation of safety equipment
  • Reviews renovation & construction plans
  • Consults on indoor air quality and other industrial hygiene issues
  • Inspects/audits research and clinical laboratory areas for compliance with federal, state and local regulation
  • Offer Research Laboratory Biosafety Training Program for the high containment laboratories on campus
  • Assists faculty in preparing documentation for review and approval by the Institutional BioSafety Committee & the Chemical Safety Committee
  • Regulatory Licenses and Registrations which are the responsibility of B&C include:
  • The Texas Department of State Health Services licenses the University of Texas Medical Branch as an Asbestos Operations and Maintenance Contractor (21)
  • The IBC is registered through the NIH Office of Biotechnology Activities (22)
  • The Department of Health and Human Services Centers for Disease Control and Prevention Select Agent Program and the Animal Plant Health Inspection Service (APHIS) Agriculture Select Agent Program provides a Certificate of Registration to The University of Texas Medical Branch at Galveston and authorizes the university to possess, use and transfer select agents and toxins as specified in the application (23)
  • Radiation Safety
    The Radiation Safety Program is responsible for ensuring that UTMB is in compliance with the following Licenses and Registrations issued by the Texas Department of Health State Services (TDSHS):

    • Radioactive Material Use License L01299
    • Certificate of X-Ray Registration R00216
    • Certificate of X-ray Registration R22369
    • Certificate of Laser Registration Z00488
    • Certification of Mammography Systems M00525
    • Certification of Mammography Systems M00976
    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 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. 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 monthly. 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, individuals with expertise in the use of radioactive materials. Other members are appointed at the discretion of the Vice-President for Research Affairs.

    The Radiation Safety Program provides the following services:
  • Assists in the development of general policies for control of radiation
  • Collects and disseminates information relative to radiation protection
  • Evaluates equipment and physical facilities
  • Evaluates operational techniques and procedures
  • Provides radiation safety training
  • Conducts an audit program to assure the laboratory facilities and procedures are in accordance with UTMB policies and Texas Administrative Codes (TAC) for Radiation
  • Provides advice on decontamination of facilities and equipment following spills or prior to remodeling or modification of facilities
  • Responds to emergencies and investigates accidental exposures
  • Aids in the completion of the “Application for Permit to Use Radioactive Material”, “Application for Laser User Permit” and “Application for Laser Registration”
  • Conducts a monitoring program for laboratory contamination
  • Conducts bioassay program for internal deposition of radionuclides
  • Issues personnel dosimetry devices and reviews reports
  • Receives and inspects packages containing radioactive materials
  • Maintains and updates an inventory of radioactive materials and radiation producing machines
  • Processes outgoing shipments of radioactive materials in accordance with federal and state regulations
  • Calibrates portable radiation survey instruments
  • Maintains records necessary to comply with TAC for Radiation
  • 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. OS&FP is intimately involved with the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) accreditation process for the University’s 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 campus 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:
  • General Safety and Life Safety Inspections:
    • Annual Building Life Safety Surveys (JCAHO)
    • Accident and Near Miss
    • Safety Showers
    • Storage/Exit Egress/Life Safety Issues
  • Testing and Inspection of all Fire Alarm Systems, Sprinkler Systems, Suppression Systems, and Portable Fire Extinguishers
  • Conducts fire drills, campus wide
  • 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
  • Investigation of campus accident reports
  • 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
  • Human Subjects
    UTMB has an organized and systematic program in place for the protection of research subjects that is in conformance with the principles and guidelines for protecting research subjects that is contained in “Ethical Principles and Guidelines for the Protection of Human Subjects of Research,” commonly known as the Belmont Report, and with the Code of Federal Regulations, Title 45, Part 46 (24). These include Respect for Persons, Beneficence, and Justice, which are achieved through informed consent, assessment of risks and benefits, and appropriate selection of subjects. To assure this, all study personnel involved in a sponsored clinical trial that have interface with human subjects of human subject material or information must complete education on the protection of research subjects. This training can be obtained on-line by completing “Protection of Human Research Participants (25).” This course must be repeated every three years. In addition, the General Clinical Research Center offers a course, “Regulation and Ethics in Clinical Research,” that consists of 10 weekly presentations by faculty from the Institute for the Medical Humanities and others that discusses important dimensions of research including the history of IRB (Institutional Review Board) and other federal regulations associated with clinical investigations (26). UTMB Research Services also offers a training program consisting of three 1.5 hour sessions entitled "Navigating the IRB and Investigator Responsibilities," developed for investigators, study/nurse coordinators, fellows, and others with responsibilities in human subjects research (27).

    Police Department
    The primary mission of the UTMB Police Department is to provide protection and professional services to the UTMB community. The Police Department staff includes 42 police officers, 33 uniformed noncommissioned guards, and 12 support and administrative personnel. The department is a full-service criminal justice agency, providing law enforcement services 24 hours a day, seven days a week, 365 days a year.

    UTMB police officers are vested with the same authority and responsibilities of any police officer of the State of Texas, while on property owned, leased, or otherwise under the control of UTMB. This includes full arrest authority. UTMB police officers are commissioned by the University of Texas 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 (28).

    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 campus.

    The UTMB Police Department maintains a close working relationship with local, county and federal law enforcement agencies. Crime-related reports and information, including incidents at recognized off-campus 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 (29).

    The crime prevention program currently in place at UTMB consists of the following services:
    Escort Programs: The UTMB Police Department provides escort service (“Safety Watch”) for persons walking on campus after dark. Emergency call boxes are utilized and enhance safety across campus.

    Crime Prevention Presentations: Crime prevention presentations are held for employees, commuter students, students with disabilities, international students, student government, faculty and staff organizations, specific campus departments, and recognized student organizations. Crime prevention presentations are included in each scheduled student orientation. To promote residence hall security, these presentations are held periodically at residence halls; at other on-campus student residences, such as fraternity and sorority houses; and at off-campus 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), and in local newspapers.

    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 campus 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 campus 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 university students and employees.
    UTMB Fleet Management Program and Vehicle Safety
    UTMB has had a complete 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 campus currently has 184 vehicles of various types in this program. They range from campus 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 (30) as reflected in the UTMB Handbook of Operating Procedures policies concerning vehicle use (31).

    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 is offered on campus on a monthly basis. 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.

    Sustainability and Energy Savings
    UTMB is committed to stewardship of the environment and promoting the principals of energy efficiency and sustainability. UTMB's commitment to energy savings goals, recycling, reductions in carbon emissions and sustainable design is evident in existing policy and practices. UTMB will continue to implement well-thought-out initiatives that increase efficiencies, reduce emissions, and promote sustainability practices that contribute meaningfully to the environment, while achieving excellence consistent with the healthcare, education and research missions of the University (32).
    #
    Source
    1
    Institutional Handbook of Operating Procedures, Table of Contents
    http://intranet.utmb.edu/Policies_And_Procedures/TOCNew/index.htm
    2
    UTMB Training and Education, Training Catalog
    http://intranet.utmb.edu/training/catalog.htm
    3
    UTMB Institutional Handbook of Operating Procedures, Section 8, Policy 8.1.13, Reproductive/ Fertility Hazards in the Workplace
    http://intranet.utmb.edu/Policies_And_Procedures/Health__Safety_and_Security/PNP_005015
    4
    Institutional Handbook of Operating Procedures, Section 8, Policy 8.1.2, Tuberculosis Surveillance Programs for Healthcare Workers
    http://intranet.utmb.edu/Policies_And_Procedures/Health__Safety_and_Security/PNP_005007
    5
    Institutional Handbook of Operating Procedures, Section 8, Policy 8.1.1, Policy and Guidelines on AIDS, HIV, and Hepatitis B
    http://intranet.utmb.edu/Policies_And_Procedures/Health__Safety_and_Security/PNP_005006
    6
    Institutional Handbook of Operating Procedures, Section 2, Policy 2.9.1, No Smoking Policy
    http://intranet.utmb.edu/Policies_And_Procedures/General_Administrative/PNP_004847
    7
    Commit to Quit Tobacco Cessation Program
    http://www.utmb.edu/hp/commit_to_quit_program.htm
    8
    UTMB Institutional Handbook of Operating Procedures, Section 8, Policy 8.2.4, Workplace Violence
    http://intranet.utmb.edu/Policies_And_Procedures/Health__Safety_and_Security/PNP_005008
    9
    UTMB Institutional Handbook of Operating Procedures, Section 8, Policy 8.1.5, Fire Alarm and Incident Response Policy
    http://intranet.utmb.edu/Policies_And_Procedures/Health__Safety_and_Security/PNP_005009
    10
    UTMB Institutional Handbook of Operating Procedures, Section 8, Policy 8.1.6, Removal/ Disposal of Hazardous Waste
    http://intranet.utmb.edu/Policies_And_Procedures/Health__Safety_and_Security/PNP_005010
    11
    UTMB Institutional Handbook of Operating Procedures, Section 8, Policy 8.1.12, Safety Training
    http://intranet.utmb.edu/Policies_And_Procedures/Search_Results/PNP_005014
    12
    UTMB Institutional Handbook of Operating Procedures, Section 8, Policy 8.1.14, Decorations Safety
    http://intranet.utmb.edu/Policies_And_Procedures/Search_Results/PNP_039197
    13
    UTMB Institutional Handbook of Operating Procedures, Section 8, Policy 8.1.19, Portable Heating Devices
    http://intranet.utmb.edu/Policies_And_Procedures/Search_Results/PNP_083086
    14
    UTMB Institutional Handbook of Operating Procedures, Section 8, Policy 8.2.1, Threatening Situations
    http://intranet.utmb.edu/Policies_And_Procedures/Health__Safety_and_Security/PNP_005002
    15
    UTMB Institutional Handbook of Operating Procedures, Section 8, Policy 8.2.4, Possession of Weapons
    http://intranet.utmb.edu/Policies_And_Procedures/Health__Safety_and_Security/PNP_005005
    16
    UTMB Institutional Handbook of Operating Procedures, Section 8, Policy 8.2.3, Identification Badges/Smart Cards
    http://intranet.utmb.edu/Policies_And_Procedures/Health__Safety_and_Security/PNP_005004
    17
    UTMB Institutional Handbook of Operating Procedures, Section 3, Policy 3.1.1, Staffing During Adverse Conditions
    http://intranet.utmb.edu/Policies_And_Procedures/Employee_Related/PNP_055701
    18
    UTMB Emergency Operations Plan
    http://intranet.utmb.edu/emergency_plan/
    19
    UTMB ID/Smart Cards
    http://www.utmb.edu/smartcard/defaultold.htm
    20
    UTMB Campus Security Report, 2006
    http://intranet.utmb.edu/securityreport/Default.htm
    21
    Texas Department of State Health Services License No. 895005, Effective 5/7/2006
    Hard copy located in the Office of Institutional Effectiveness
    22
    Department of Health and Human Services Letter from Eugene Rosenthal to Dee Zimmerman, dated April 23, 2007
    Hard copy located in the Office of Institutional Effectiveness
    23
    Centers for Disease Control and Prevention Letter from Robbin Weyant to Michael Shriner and Certificate of Registration, both dated April 9, 2007
    Hard copy located in the Office of Institutional Effectiveness
    24
    U.S. Department of Health and Human Services Code of Federal Regulations, Title 45, Part 46
    http://www.hhs.gov/ohrp/humansubjects/guidance/45cfr46.htm
    25
    UTMB Online Training, Protection of Human Research Participants
    http://training.utmb.edu/core/core_catalogitems.asp?Page=49
    26
    UTMB General Clinical Research Center, Clinical Research Education, Regulations and Ethics in Clinical Research
    http://www.utmb.edu/gcrc/education/Ed_EthicsModule.htm
    27
    Navigating the IRB and Investigator Responsibilities
    http://research.utmb.edu/research/yellowsheet/ys070319.htm#article1
    28
    Texas Education Code, Chapter 51, Subchapter E, Section 51.203, Campus Peace Officers
    http://tlo2.tlc.state.tx.us/statutes/docs/ED/content/htm/ed.003.00.000051.00.htm
    29
    UTMB Campus Alert Status
    http://intranet.utmb.edu/
    30
    UT 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/policy/policies/uts157.pdf
    31
    UTMB Institutional Handbook of Operating Procedures, Section 8, Policy 8.1.15, General Requirements for Use of Vehicles
    http://intranet.utmb.edu/Policies_And_Procedures/Health__Safety_and_Security/PNP_004999
    32
    University of Texas Systems Policy 169 Sustainability Practices
    http://www.utsystem.edu/policy/policies/uts169.html
    The Texas Department of State Health Services has completed the following audits:
  • UTMB Radioactive Material Use License L01299 on July 19 and 20, 2006 and found the radiation safety program in compliance (24).
  • UTMB Certificate of X-Ray Registration R00216 on March 21, 2007. No violations were noted (25).
  • UTMB Certificate of Mammography Systems on February 28, 2007. No health violations were found during the inspection. A Certificate of Inspection was issued to UTMB (26). This certificate is only being issued to those facilities that are clearly above the average in comparison with their peers.
  • Environmental Protection Management
    The Environmental Protection Management (EPM) program performs in a team-based approach to provide day-to-day environmental management activities throughout the UTMB campus community. Listed below are routine program services:
  • Manage the Hazardous Waste Disposal Program – implement federal, state, and local regulations pertaining to the handling, storage, transportation, recordkeeping, and disposal of hazardous waste
  • Provide technical assistance and training to the university community on identifying and disposing of waste
  • Provide assistance to personnel working with processes that generate hazardous chemicals or wastes in applying source reduction and waste minimization measures – program examples include silver reclamation for film developing, solvent distillation, and mercury reduction
  • Inspection or audit campus for environmental compliance.
  • Develop and manage air and water pollution control strategies, plans, and programs
  • Provide 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 campus 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. UTMB maintains operational control of construction project plans and specifications, including the ability to make modifications as required. The contractor is responsible for the day-to-day operational control of activities necessary to ensure compliance with a Storm Water Pollution Prevention Plan (SWPPP) for the site. The contractor will be required to obtain permit coverage along with UTMB.

    In 2005, EPM implemented an Environmental Management System that 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 campus-wide.

    In 2006, TCEQ staff audited UTMB’s environmental compliance programs to assess performance and identify improvement opportunities. TCEQ recommended UTMB to the Environmental Protection Agency (EPA) National Environmental Performance Track (NEPT) program; a program for recognizing top environmental performers (27). As a member to the NEPT program, UTMB has committed to sound environmental management, continuous improvement, public outreach, and sustained environmental compliance through 2010 (28).