THE UNIVERSITY L Laboratory Safety

OF MELBOURNE
Faculty of Medicine, Dentistry 1 Writing Policies & Procedures
and Health Sciences

Summary
Information on how to conduct University activities safely shall be developed at University, Faculty and Local
levels to ensure that policies, safe work procedures, protocols, guidelines and requirements are outlined
clearly in an appropriate format.
Environment, Health and Safety Manual
Policies and Procedures follow the format as described in the EHSM:
Reference: http://www.unimelb.edu.au/ehsm-new/10.html#10.1.
Faculty Environment, Health and Safety Policies Manual
Documents in the Laboratory Safety and Workplace Safety sections are prepared in the following Format:
1. Summary – description of the section and reference to legislation and the EHSM.
2. Requirements – description of the specifics of the policy or procedure including responsibilities.
3. Risk Assessments – where applicable for activities or equipment.
4. Procedures/Guidelines – guidelines for risk control.
5. Document Control – Date, Authorisation, Pages, Version (if applicable).
Department, Centre and School Safe Work Procedures (SWPs)
Should be prepared in collaboration with staff, students and the Faculty EHS Manager for all locally based
activities such as laboratory work activities where a potential hazard may exist.
The process for introducing and reviewing Safe Work Procedures is as follows:
1. Identification of a hazard through information from external or internal sources.
2. Conduct of Risk Assessments to determine the level of risk.
3. Development of control measures or guidelines that form part of a Safe Work Procedure
4. Review of the Safe Work Procedure and Risk Assessment at an appropriate time – 2 to 3 years.
Important Notes:
- It may not be necessary to have documented work procedures for very low risk tasks.
- Where staff or students are trained in a safe work procedure, that training must be documented.
- All local safe work procedures must be authorised by an appropriate person

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Date: September 2007 Version 2.1 Authorised: Faculty EHS Committee  The University of Melbourne
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General Requirements
Local Safe Work Procedures
The development of local safe work procedures which may be known as operational manuals, protocols,
methods etc shall ensure the inclusion of safe work methods to ensure that any staff or student learning the
procedure or using the methodology will be able to undertake the activity safely and ensure that there is
minimisation of the risk to the environment.

There are many accepted methodologies for preparing safe work procedures, one has been outlined below:

Title Name of procedure

Introduction
Principles / Scope
Safety Management
Licences / Permits
Training / Competency
Risk Management
Equipment
Operating Procedure
Controls / Calibration
Waste Disposal
Emergency Procedures
References
Include a procedure number for easy identification
Explanation of the protocol
Background information
The aim of the procedure
What activities are covered in the procedure
Outcomes of risk assessments
- Engineering requirements (hoods, ventilation etc)
- Administrative controls
- Personal protective equipment required
Licences of staff ie forklift driver
Permits to work ie Poisons, AQIS
The training requirements for staff/students undertaking this procedure
- Competency based training
- Demonstration only
- No specific training needs
Attach the actual risk assessments to the back of the procedure
Reference common risk assessments (where used)
Detail the type of equipment to be used
- location
- requirements for training in that particular item
- cleaning / maintenance (if not covered in a separate procedure)
The methodology and steps
Include safe work requirements
Include where equipment may require to be calibrated before use
What to do with the end product or waste generated
- Where waste containers are located
- Labeling requirements
- Other disposal methods
What to do if there is a spill, containment breach or other incident
Optional to include source documentation for this procedure

Always remember to have document control to state the following:

- Date prepared
- Date to be reviewed
- Authored by
- Authorised by
- Document number / procedure number

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Date: September 2007 Version 2.1 Authorised: Faculty EHS Committee  The University of Melbourne
 L 1 Writing Policies & Procedures

Guidelines for the Faculty EHS Webpage

Review Guidelines
All Faculty policies, procedures and guidelines (including checklists and forms) shall be developed and
revised in consultation with the Faculty EHS Manager, Faculty EHS Committee, Nominated Health and
Safety Representatives and selected staff from time to time. The Custodian of all Faculty documents is the
Faculty EHS Manager. All Faculty Policy, Procedure and Forms should follow the guidelines specified below
for review:
♦ Faculty Safe Work Procedures to be reviewed 3 yearly (from date of publication)
♦ Faculty Checklists and Forms to be reviewed 2 yearly (from date of publication)
♦ Faculty EHS Webpage content and structure to be reviewed 3 yearly – January 2010
Legislation Review
The Faculty EHS Manager receives regular updates of legislative changes and guidelines from the
Environment Health and Safety Unit and other external sources. Where these changes directly impact on the
Faculty, the EHS Manager will draft appropriate changes to existing material to reflect new requirements. All
revised documents are to be approved by the Faculty EHS Committee.
Risk Management
The Faculty EHS Manager will use legislative updates, incident reports, Worksafe guidance notes and other
information to identify workplace hazards. Where a significant hazard has been identified and there are key
issues to be addressed at a Faculty level or the risk has not been assessed through the University EHSM, the
completion of risk assessments for relevant safe work procedures requires a consultative process involving the
relevant staff and students and may include specialised working groups.
The risk assessment process is undertaken using the EHSM Section 3 Identification, Assessment and Control
which uses the Risk Management Methodology. The applicable forms are located in the EHSM.
Completed risk assessments where a level of risk has been documented will require the implementation of
control strategies which will follow the Hierarchy of Control. The Faculty Safe Work Procedures manual
details appropriate controls in the Procedures section of the relevant documents.

Faculty Objectives and Targets

The Faculty through the EHS Committee will set yearly Objectives and Targets in line with EHS activities
within the Faculty, and will reflect where relevant University based Objectives and Targets. The Faculty EHS
Manager is responsible for overseeing the objectives and targets. Objectives have the following information:
♦ Primary Objective
♦ Priority Rating and Risk Assessment Rating
♦ Key Targets and Timelines
♦ Milestones and Dates
♦ Outcomes
♦ Date of Production
♦ Legislative Requirements
♦ Accreditation Requirements
♦ Other Requirements

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Date: September 2007 Version 2.1 Authorised: Faculty EHS Committee  The University of Melbourne