1. Purpose

This policy is intended to formalize Vanderbilt University€™s commitment to safety, health, and environmental protection and define the strategy for achieving and maintaining university-wide compliance with all environmental, health, and safety laws and regulations.

2. Commitment

Vanderbilt University will support and maintain a strong commitment to safety, health and environmental protection through:

• Assuring compliance with federal, state and local safety, health and environmental requirements;
• Minimizing hazards, reducing pollution and continuously improving our practices regarding safety, health and environmental protection;
• Empowering our faculty, staff, and students to demonstrate individual and institutional leadership in all matters pertaining to safety, health and environmental protection while preserving academic freedom in research and education and evidence-based practices in patient care;
• Protecting and maintaining safe and secure facilities for teaching, patient care, research, living and work;
• Emphasizing open communication with our community regarding safety, health and environmental issues;
• Instilling the values of environmental stewardship and conservation of resources in our future leaders.

3. Roles and Responsibilities

Vanderbilt University includes ten undergraduate and graduate schools, Vanderbilt University Medical Center, and an extensive network of support functions necessary to the operation of the institution. The management structure of the University is complex and generally decentralized. However, the University is considered to be one entity from a legal, regulatory, and public perspective, and is held accountable as such by federal, state, and local authorities and granting agencies. Therefore, the actions of the University€™s individual constituents are those of the entire University.

The roles and responsibilities of disparate University units and constituents within this strategy are identified and described below:

1. Members of the VU Community (Faculty, Staff, Students, and Contractors)
   
   It is the responsibility of individuals at VU to conduct their activities in a safe manner and in compliance with all applicable policies, laws, and regulations. This responsibility includes participation in training, abiding by established safety procedures and reporting safety hazards and/or potential violations of regulations to their supervisor.
    
2. Supervisors (Principal Investigator, Laboratory Supervisor, Instructor, or Administrative Supervisor)
   
   Supervisors are responsible for compliance with environmental health and safety standards and policies as well as applicable local, state, and federal regulations under their authority. Supervisors are responsible for assessing the potential hazards associated with the tasks of the participants in the programs under their authority, reducing or eliminating identified hazards, communicating those hazards and protective measures to the participants in their programs, and for determining the ability of those participants to perform their tasks safely. Therefore, each supervisor is responsible for ensuring that participants in their programs are adequately trained. Supervisors are also responsible for facilitating internal and external inspections and audits as well as taking prompt action when unsafe or non-compliant acts or conditions are discovered or reported to them. Supervisors must report unsafe acts or conditions, non-compliance, injuries, or incidents to the appropriate internal department.
    
3. Deans, Department Chairs, and Program Directors
   
   It is the responsibility of Deans, Department Chairs, and Program Directors at VU to ensure that each academic or administrative unit under their authority conducts its operations in accordance with all applicable laws, regulations and VU policies. This responsibility includes, but is not limited to, ensuring the use of appropriate safety practices, equipment, and facilities in activities under their authority; establishing safety programs (including safety committees) in their school, department or center; and implementing specific school, department, or center-level policies and procedures for safety and compliance.
    
4. Executive Administration (Chancellor, Vice-Chancellors, Asst/Assoc Vice-Chancellors, Provost, and Hospital Administrators)
   
   Executive Administration provides appropriate financial and organizational support to assure VU operations are conducted safely and in compliance with applicable environmental, health and safety laws and regulations. Executive Administration approves and authorizes the implementation of policies and programs for safety and compliance including the establishment of consequences for non-compliance as well as unsafe acts or creating unsafe working conditions.

4. Environmental Health and Safety Management

In order to maintain compliance and manage the multitude of issues associated with environmental health and safety regulations and laws, an Environmental Health and Safety Management System (EHSMS) has been established. This management system includes: Vanderbilt Environmental Health and Safety department, the use of safety-related University Standing Committees for oversight and policy development, and the Compliance Offices that provide a framework for the assessment and documentation of compliance activities.

These constituents within this EHSMS are identified and described below:

1. Vanderbilt Environmental Health and Safety (VEHS)
   
   Vanderbilt Environmental Health and Safety (VEHS) department is funded and supported by Vanderbilt University to serve as a central management resource on matters related to environmental health and safety. VEHS serves as a technical resource and provides a broad range of environmental health and safety services to the University community including: development of policies and programs, assessment and control of safety and environmental hazards, management of a central chemical and radioactive hazardous waste facility, a hazardous materials emergency-response team, and management of a comprehensive web-based learning management system for safety training and hazardous materials inventory management. VEHS provides impact analysis and required oversight of environmental health and safety regulatory requirements that impact University operations. VEHS also coordinates the University response to matters pertaining to external regulatory inspections, enforcement actions, investigations or employee complaints related to workplace safety or environmental compliance.
   
   VEHS also coordinates the activities of the University Standing Committees (described below) and assists in the selection and appointment of Chairs and members.
    
2. University Standing Committees
   
   Five University Standing Committees are chartered to manage environmental health and safety issues. Faculty for these committees are appointed by the Chancellor, through nomination by the Faculty Senate. Administrative members are appointed by the Chancellor through nomination by appropriate Vice-Chancellors.
    
   1. Environmental Health and Safety Oversight Committee (EHSOC)
      The EHSOC acts as an oversight body for all safety-related university standing committees. This committee provides executive-level leadership and serves as a resource on environmental health and safety compliance. The EHSOC is chaired by the Vice-Chancellor of Administration and is comprised of a broad cross-section of representation throughout the University, Chairs of each safety-related University Standing Committee, and Chairs of each individual school/department safety committees.
   2. Radiation Safety Committee (RSC)
      The RSC ensures the safe use of radioactive materials and ionizing radiation-producing equipment and its compliance with the State of Tennessee and federal regulations, broadscope license conditions and certified registrations. This committee reports through the Vice-Chancellor for Administration.
   3. Institutional Biosafety Committee (IBC)
      The IBC is charged to consider policies and procedures pertaining to the safe handling, transport, use, and disposal of biological materials, including recombinant DNA molecules; and to review research using biological materials for compliance with guidelines established by the NIH and CDC. This committee reports through the Provost and Vice-Chancellor for Academic Affairs.
   4. Environmental Affairs Committee (EAC)
      The EAC considers policies and procedures that create a comprehensive environmental compliance program for Vanderbilt University and assists campus and medical center units in complying with Environmental Protection Agency (EPA) and Department of Transportation (DOT) regulations. This committee reports to the Vice Chancellor for Administration.
   5. Chemical Safety Committee (CSC)
      The CSC considers policies and procedures pertaining to the safe handling, transport and use of chemicals, and assists schools/departments/units with managing compliance with regulations and/or guidelines of the Environmental Protection Agency (EPA), the Occupational Safety and Health Administration (OSHA), National Institutes of Occupational Safety Health (NIOSH) and others pertaining to hazardous chemicals. This committee reports to the Vice-Chancellor for Health Affairs.
       
3. Compliance Offices
   
   A Compliance Officer is designated for both VU and VUMC. It is the responsibility of these Compliance Offices to inform the University community about the Standards of Conduct and ethical obligations under the Compliance Program; to monitor compliance activities which includes policies, procedures, training, and education programs; to serve as a resource to the University on matters of compliance; and to maintain a helpline for compliance matters.

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