Policy Category: 
Health and Safety
Approved By: 
Executive Team
Effective Date: 
February 15, 2005 [Revised 5 February 2008; 24 November 2015]


1.   Preamble

Some University endeavours involve work with potentially hazardous materials.  For biological hazards, the potential for harm extends beyond oneself and one's colleagues to the local and regional communities.
In Canada, the federal government has developed policies and procedures in order to fulfill its mission to safeguard the health of all Canadians under the auspices of the Health of Animals Act and Human Pathogens & Toxins Act.  Guidelines for dealing with biological hazards in laboratories have been developed by the Office of Lab Biosafety & Biosecurity, which is part of the Centre for Emergency Preparedness and Response, established within the Public Health Agency of Canada, under the jurisdiction of the Minister of Health.
It is required by the federal research granting councils that Lakehead University integrates recognition, evaluation and control of biological hazards on campus and ensures compliance with applicable federal government guidelines.

2.   Policy

The Board of Governors of Lakehead University recognizes and accepts its responsibility for controlling hazards that may be associated with teaching and research activities.  
It is the policy of Lakehead University to manage the risk associated with biological hazards in order to provide faculty, students and researchers access to pathogens requiring up to Level 2 containment while ensuring that the University and surrounding communities are protected.
Lakehead's comprehensive risk management program for biological hazards, the Biosafety Program, consists of this policy and associated guidelines, procedures and training (information delivery).  The program will be overseen by the Biosafety Committee, which reports to the Vice-President Research.  All faculty, staff, researchers and students who work with biological hazards will act in accordance with the program.

3.   Guidelines

The technical document "Canadian Biosafety Standards" prepared by Public Health Agency of Canada's Office of Lab Biosafety & Biosecurity forms the basis for the Lakehead University Laboratory Safety Operating Procedures.

4.   Procedures

4.1. Committee procedures for recognizing, evaluating and controlling biological hazards are established according to the Biosafety Committee terms of reference.
4.2. Each laboratory involved with biological hazards will develop, document and implement workplace specific procedures, following the Lakehead University Laboratory Safety Operating Procedures. These procedures will be evaluated and approved by the biosafety committee.

5.  Management of non-compliance with this policy  

5.1 The Lakehead University Biosafety Committee is responsible for post-approval monitoring of biosafety protocols and for determining and working to correct breaches of conformity. Breaches of conformity that cannot be corrected by the Biosafety Committee working with the Permit Holder, who is responsible for the biosafety project or class, will be referred to the senior administration, which must determine sanctions that will be taken.  Appropriate Dean, and Chair, or Director will be notified.  Unresolved breaches of conformity related to research activities will be referred to the Vice President (Research).  Unresolved breaches of conformity related to teaching activities will be referred to the Vice President (Academic) & Provost.  It is the purview of the Vice President to determine whether the unresolved breach of conformity constitutes non-compliant activities.  The response to non-compliant activities can include suspended access to funding, or laboratory facilities.  

5.2 When an allegation of non-conformity is made, the Chair of the Biosafety Committee and/or Biosafety Officer shall investigate the matter and determine whether the allegation is valid. This may involve comparing the approved protocol or standard operating procedures approved by the Biosafety Committee with the alleged activities.  In cases where the allegation is found to be valid upon investigation, the Chair will proceed as follows:

5.2.1 The Chair of the Biosafety Committee will inform the Permit Holder in writing that a breach in protocol has occurred and specify time to rectify the breach. In the meantime, the Biosafety Committee will be advised of the situation. Should the written response of the Permit Holder be insufficient, the Chair will schedule an emergency meeting of the Biosafety Committee.

5.2.2 The allegation to and the response from the Permit Holder will be discussed at the emergency meeting. The Committee must then make one of the following determinations:

a) The response to the allegation is adequate. No further action is required.

b) The response to the allegation is inadequate and the allegation involves minimal risk (as determined by the Committee). Recommendations must then be sent to the Permit Holder, and a specified time period will be set for the issue to be resolved.

c) The response to the allegation is inadequate and the allegation involves, or could potentially involve, significant risk. Recommendations to suspend activities will be sent immediately to the Chair, to the Biosafety Officer and to the appropriate Vice-President by the Committee as per section 5.1.

5.2.3. In the event the Chair or other designated individuals from the committee discovers conditions which pose an immediate threat to laboratory workers, community or the environment, the Chair and Biosafety Officer or one other designated individual from the Committee can recommend immediate action to the Vice-President. The recommendation can include the immediate suspension of the related activity.

5.3 The decisions of the Committee shall be documented in writing. All correspondence directed to the Permit Holder will be copied to both the Department Chair and the Dean.

5.4 Recommendations to the Vice-President shall be made in a formal letter detailing the following:
    1) The issue
    2) The alleged infraction
    3) Steps taken to resolve the issue
    4) Recommendations of the committee
    5) Time period for response to be made to the committee.

6.   Training/Information Delivery

Wherever applicable, awareness of the biosafety program is included in new employee and student orientation.  The responsibility for providing this orientation and for ensuring that standards and guidelines are understood is the responsibility of the Office of Human Resources – Health & Safety. Orientation and proficiency in the laboratory specific procedures belongs to the supervising faculty/staff member.  Faculty Deans, Chairs and Directors have the responsibility for ensuring that faculty members carry out the requirements of this section.
Additional information for the Biosafety Program (General Laboratory Procedures Containment Level 1 and 2, and application guidelines and forms) are available by contacting the Laboratory and Biosafety Officer in the Human Resources Office.