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5400 Documentation and Recordkeeping |
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1.0
Introduction
Jefferson
Lab has many legal obligations to create, collect, and maintain Environmental,
Safety, Health, and Quality (ESH&Q)-related information. Local, state, and federal safety, health, and
environmental protection agencies and officials must be ensured access to
information in certain areas of ESH&Q management. As well, information and documents must be
kept current.
This
chapter identifies the general ESH&Q documentation and recordkeeping
requirements at Jefferson Lab that are derived from external and other
contractual commitments. Many specific
program requirements are provided in other ES&H Manual chapters.
This
chapter will show you:
- that many of the ESH&Q program activities
at Jefferson Lab customarily have documentation and/or recordkeeping
requirements,
- who is responsible for preparing and
maintaining ESH&Q-related records,
and
- ESH&Q-related documentation issues that may
be of concern in your job.
There
may also be other program-specific documentation and/or recordkeeping
requirements identified within your own work group.
2.0
Responsibilities
2.1
Supervisors/ Subcontracting
Officer’s Technical Representatives (SOTRs)/Group Hall
Leaders/Sponsors
·
Ensure
that required records
are forwarded to the appropriate files
custodian.
2.2
Asbestos
Program Manager
·
Manage
document preparation related to Jefferson Lab Asbestos Management Plan.
·
Maintain
applicable records
relating to AMP requirements.
2.3
Spill Prevention, Control, and
Countermeasures (SPCC) Coordinator
·
Assist
supervisors with document preparation.
·
Maintain
applicable information relating to SPCC Plan requirements.
2.4
Subject Matter Coordinator/Subject Matter Expert
·
Provide guidance to line managers regarding documentation and recordkeeping
requirements related to the Hazard Issues
for which you have responsibility as described in ES&H Manual Chapter 2410 Hazard Issues and Contractual Commitments.
2.5
ESH&Q
Officers
·
Maintain records of
safety inspections.
·
Enter inspection results
into a tracking system.
·
Ensure documentation
reflects closure of any findings.
2.6
Material Safety
Data Sheet (MSDS)
Library Coordinator
·
Maintain
the Jefferson Lab MSDS
library.
·
For
materials that have not been on-site for five years or more, send the MSDS to be
archived to the ESH&Q Reporting Manager.
2.7
Business
Services Manager
·
Annually
prepare documentation on affirmative procurement actions in support of Resource
Conservation and Recovery Act (RCRA) and other contractual commitments and
provide a copy to the ESH&Q Reporting Manager.
2.8
Jefferson
Lab Records Manager/Archivist
·
Oversee
the storage, retrieval, and destruction of temporary records.
·
Coordinate
disposition
of records,
including transfer to Federal Records Storage or Archives, or destruction.
·
Review
record
schedules to determine correct disposition
of records
in storage.
·
Maintain
the Jefferson Lab Records Holding Area and Archive.
2.9
General
Counsel
·
Maintain a resource for
legal documents.
·
Maintain records of
lab legal contracts, etc. with ESH&Q applicability.
·
Maintain records of
changes in facility ownership.
2.10
Jefferson
Lab Training and Performance Manager
·
Maintain
the Jefferson Lab personnel training files using data provided by instructors
and supervisors.
2.11
ESH&Q
Files
Custodians
·
Create
and maintain ESH&Q filing systems under the direction of the Records
Manager, as needed.
·
Prepare
records
for storage according to regulatory requirements and the Jefferson Lab
Records Management Handbook.
·
Maintain
an office records
management file for records
placed in storage or disposed of.
2.12
Jefferson
Lab Industrial Hygienist/Hazardous Waste Coordinator
·
Retain records of:
o
results of hazardous
substance monitoring,
o
test results, waste
analyses,
o
Satellite Accumulation
Area (SAA)/Central Accumulation Area (CAA) inspection records,
o
pretreatment/sampling records, and
o
records of sampling equipment calibration.
·
Manage Hazardous Air
Pollutant (HAP) performance test data, as necessary.
·
Assist in the preparation
of:
o
•emergency and hazardous chemical
inventories, and
o
•toxic
chemical release reports.
2.13
Occupational Medicine
·
Maintain
records
of:
o
•employee
exposure to potentially hazardous materials,
upon receipt,
o
analyses
using exposure or medical
records, and
o
tracking and shipping forms for all
medical wastes.
·
Retain
records of
significant adverse reactions to human health claimed to be caused by chemical
substances, as identified.
2.14
Facilities
Management Director
·
Maintain
all equipment-related records per
division procedures.
·
Maintain
certifications for all staff involved in refrigeration or air conditioning
maintenance and ensure that subcontractors are certified.
·
Ensure
subcontractors have all appropriate training and certifications for area of
work, including pesticide management.
2.15
Radiation
Control Group
(RadCon) Department Head
·
Document and maintain records of:
o
equipment calibration,
o
radiation exposure,
o
investigations,
o
internal minor Price
Anderson Amendments Act and radiation incident reports, and
o
radiation exposure records.
2.16
ESH&Q
Reporting Manager
·
Provide an appropriate
repository for:
o
Operational
Safety Procedures(OSPs), Standard
Operating Procedures (SOPs), and Temporary
Operational Safety Procedures (TOSPs),
o
accident, injury, and
illness records,
o
motor vehicle and property
damage records,
o
hazardous waste
information including medical waste manifests, and hazardous waste generation
data,
o
occurrence
reporting records,
o
environmentally harmful
material release reports (chemicals, oil, and other harmful materials),
o
non-radiation and
permit-related radiation monitoring
and sampling records,
and
o
archived MSDSs.
·
Maintain records of
incidents at similar facilities for sharing as lessons-learned experiences.
·
Retain and maintain records of:
o
Hampton Roads
Sanitation District (HRSD) Permit discharge and effluent information,
o
non-hazardous materials
recycling and disposition,
o
HRSD-permitted
meter calibration results,
o
annual occupational injury
and illness logs, supplementary records, and
summaries,
o
fatality and multiple
accident reports,
o
emergency and hazardous chemical
inventories,
o
MSDSs and
lists of hazardous
chemicals submitted to emergency planning groups, and
o
toxic chemical release reports.
·
Prepare and maintain records
involving actions concerning oil/fuel storage and use.
·
Retain records of
significant adverse reactions to the environment, safety, or health claimed to
be caused by chemical substances.
·
Upon being ready for
disposal or archival of a particular record or document,
notify the appropriate File Custodian
to either dispose of the document or how to otherwise handle it.
·
Document and record lab
performance on ESH&Q performance
metrics identified in DOE contract.
·
The ESH&Q Reporting
Manager maintains record copies
of all Environmental
Management System (EMS) documentation,
including the related SOPs, on
behalf of the EMS
Management Representative.
2.17
EMS
Management Representative
·
In collaboration with the
Director’s Council, approve the Level I EMS Plan.
·
Issue and maintain the
approved Level I EMS Plan.
·
Designate a Document Owner
for Level II Environmental
Management Procedures (EMPs). The EMS Management
Representative, along with the Director’s Council, approves each Level II EMP. Issue and maintain both paper and electronic
copies of each Level II EMP. He/She authorizes all revisions to EMPs and
retains copies of both the completed EMS Document
Revision Request Form (EMP-07A) and the EMS Document
Control Matrix (EMP-07B).
·
If not previously
assigned, designate a Document Owner (author) for Level III EMS SOPs. Provide technical validation of these SOPs prior to
issue. The Document Owner’s supervisor
or department head, whomever is higher, shall approve
the SOP as
stated in ES&H
Manual Chapter 3310 Standard Operating Procedures and
Operational Safety Procedures.
·
Maintain, or through a
designee, the records
control chart (EMP-13A).
3.0
Program
Summary
3.1
General
Documents that are well written and maintained keep recorded information accessible to interested parties. Documentation and recordkeeping are used at Jefferson Lab to ensure that ESH&Q activity information is available to local, state, and federal regulatory agencies, as well as to the Department of Energy (DOE) and internal lab groups.
Preservation of most records is required by law. Preservation, storage, and disposal guidance is provided in this chapter, ES&H Manual Chapter 5400 Appendix T1 Summary of ESH&Q Documentation Requirements, EMS Procedures, and in division procedures.
The following is a list of some of the site programs that have ESH&Q documentation and recordkeeping requirements. See ES&H Manual Chapter 5400 Appendix -T1 Summary of ESH&Q Documentation Requirements for the complete list of identified documentation and recordkeeping requirements.
3.2
Important ESH&Q Programs Requiring Records Management
Most ESH&Q programs require some form of documentation and/or recordkeeping. This list highlights the main ESH&Q
programs and shows a few examples under each.
A more thorough list, including requirements, is provided in ES&H Manual Chapter 5400 Appendix -T1 Summary of ESH&Q Documentation
Requirements.
3.2.1
Workplace Safety Management under the DOE
·
annual occupational injury and illness logs and supplementary records
·
annual summary of occupational injuries and illnesses
·
fatality and multiple injury reports
·
OSP
and associated work control documents
3.2.2
Fire Protection Program
·
alarm
investigation reports
·
system
test records
·
as-built
drawings
3.2.3
Personnel Exposure to Hazardous
and Other Materials
·
periodic medical tests
3.2.4
Radiation-Contamination Control Program
·
personnel
radiation dose exposure records
·
routine
contamination surveys
3.2.5
Individual Employee
Radiation-Related Health Hazard Information
·
skin
contamination records
·
direct
measurement results
3.2.6
Environmental Management System
Plan
·
Environmental
management plans (EMPs)
·
Level
III procedures, as identified
3.2.7
ESH&Q Management
·
Radiation
o
instrument
calibration records
o
Personnel Safety
System (PSS) inspections
·
Air
programs
o
refrigerant
recycling
o
Hazardous
Air Pollutants (HAPs)/National
Emission Standards for Hazardous Air Pollutants (NESHAPs) Monitoring
·
Water
programs
o
Industrial
Wastewater Permit records
o
Virginia
Pollutant Discharge Elimination System VPDES Permit records
·
Superfund
and Emergency Planning and Community Right-to-Know Act (EPCRA)
o
MSDSs and
lists of hazardous
materials
o
emergency
and hazardous
chemical inventory form
·
EMS
o
records cited
in EMS
Level II EMPs
(See EMP-15A) that include many of the air, water, and waste records noted
in this list
o
records cited
in Level III documents (see EMP-15A)
·
General
Programs
o
equipment
inspection
o
Affirmative Procurement
Reports
3.2.8
Environmental Contamination Measurement Documentation
3.2.8.1
Hazardous
and Non-Hazardous Materials Disposal
·
Radioactive Waste
o
date of disposition
o
control data
·
Hazardous wastes
o
waste shipments
o
test results and waste analyses
o
generation records
·
Medical Wastes
o
tracking forms
·
Non-hazardous materials
disposal
o
recycling records
o
waste disposal records
·
Wastewater disposal
o
pretreatment and disposal records
o
HRSD Permit
requirements
3.2.8.2
Hazardous
Materials Transportation
·
radioactive material transfers
·
shipment of hazardous
materials
3.2.8.3
Medical,
First Aid, and Personal Injury Files
·
periodic
medical tests
·
medical
records
tracking
3.2.8.4
Motor
Vehicle Operation
·
accident
files
·
reports
4.0
Program
Requirements
4.1
Records
retention
A specified record must
be retained for an established period of time.
Some records
containing ESH&Q information with architectural, historical, or technical
value to the facility need to be retained indefinitely. The specified retention period for most
ESH&Q-related records can
be found in ES&H Manual Chapter 5400 Appendix T1 Summary of ESH&Q
Documentation Requirements, in the General Records
Schedule. The Records Manager will
coordinate the establishment of other appropriate retention periods.
The appropriate files
custodian is responsible for maintaining records until
they become inactive (used less than once per month) or have surpassed the
required retention period. When records
become inactive, they may be transferred to a records
holding area on-site or to the archives,
depending on the required action. When records pass
the required schedule, they may be archived or destroyed.
When you are maintaining records in
your work area, store the original or copied documents in such a way as to
preserve the integrity of the information.
All information that is considered personnel sensitive, including
medical records,
must be handled so as to maintain its confidentiality. These materials must be stored in a secure
location for the duration of the required retention time.
4.2
Records
transfer
When the retention period has not yet expired, but the files have
become inactive, they may be transferred to the Jefferson Lab Records Holding
Area (RHA). This is a secure area
maintained by the Records Manager accessible to authorized personnel only. The files
custodian is responsible for preparing inactive records for
storage, along with the Records Disposition and Retrieval Request (RDR), as
outlined in the Jefferson
Lab Records Management Handbook.
These records
are sent to the Manager, who will assign a records management
(RM) box number and location to the stored materials. It is important to maintain a log sheet of
this information in order to retrieve files at a later date. A copy of the log sheet is provided in ES&H Manual Chapter 5400 Appendix T2 Forms and Schedules. You may contact the Records Manager at ext.
7805 for forms or assistance.
4.3
Archived
materials
Some records that
have exceeded their legally defined retention periods should be retained for
their possible enduring historical ESH&Q value. In these cases, the documents are transferred
to the Records Manager for archiving. Records that
may need to be archived include information on the origin, organization,
procedures, and functions of the Jefferson Lab project that could act as a link
in the historical chain of Jefferson Lab activities or events. This includes:
·
documents that detail the architectural design characteristics of
the facility, and
·
other relevant reports, studies, proposals, proceedings, or records of
correspondence.
One example of archived ESH&Q-related documents is the MSDS for
materials that were used on-site. This
information is archived by ESH&Q Reporting once the material has been
absent from the site for five or more years.
If you have records that
you feel may need to be archived, or are unsure of the historical value of
certain documents, label as such and submit them to the Records Manager. The Records Manager will review the documents
to determine if they should be transferred to archives or
discarded.
4.4
Records
retrieval
Records
that are placed in storage with the Records Manager may need to be accessed
from time to time. These records may
be accessed by obtaining and completing an RDR form obtained from the Records
Manager at ext. 7805, or submitting a request electronically on the web. When completing this form, you must include
the RM box number and the location of the box that was identified to the files
custodian when the records were
placed into storage. Submit this form to
the Records Manager, or call to initiate the retrieval process. Once you have retrieved the information you
need, return the box to the RHA.
4.5
Disposition/destruction
of stored records
The Records
Manager will review the records
schedule and compile a list of boxes to be disposed of, either by
destruction, transfer to archives,
or transfer to a Federal Records Center, based on the information supplied to
the Manager on the Records Inventory and Disposition Schedule (RIDS) form and
RDR form. Prior to disposal, the records
manager shall contact the appropriate files custodian
to verify that the correct files are being disposed. After concurrence by the files custodian,
or ninety days after contacting the custodian, the Records Manager may continue
with the disposition
process.
4.6
Destruction of Records
Once scheduled records have
exceeded the specified retention period, and they do not need to be transferred
to the Federal Records Storage or to the archives,
they may be destroyed. Retained records that
do not have a scheduled retention period should not be destroyed prior to
gaining approval from the Records Manager.
Other records
may be disposed after they have reached their cut-off period. When in doubt, contact the Records Manager.
Once the Records Manager has reviewed
the records
to be disposed, and approval granted, records may
be disposed of according to the guidelines below.
·
Paper records to be
disposed of normally (not containing sensitive information) may be deposited
directly to a waste paper recycling container.
·
If the records are
restricted because they contain information that is exempted from disclosure,
including personnel sensitive materials, they must be shredded or otherwise
destroyed.
·
If the records
cannot be recycled or otherwise salvaged, they can be disposed of into the
normal trash or destroyed by other suitable means.
4.7
Duplication
of Records
In the event that identical records are
held by more than one person on-site, the original document (so labeled) shall
be considered the primary record and
shall be retained by the appropriate files
custodian. In this case, all
secondary records
(non-original copies) may be destroyed, as these are considered
“non-record.” Prior to the destruction
of so called “copies,” verify that the primary record owner
has appropriately labeled the primary record as
“original.”
4.8
Performance
Measure Tracking
Performance
measure tracking is a quantitative measure used to ensure that requirements
in the DOE/JSA contract are being fulfilled, including the areas of
non-hazardous waste disposal and recycling.
Some of the records
mentioned in this chapter and the appendix may be used for the purpose of
measuring performance in certain areas of ESH&Q Management. Contact ESH&Q Reporting for additional
information on ESH&Q performance
metrics.
5.0
References
·
Contract
DE-AC05-06 OR 23177 between DOE and JSA
·
Records
Maintained on Individuals (Privacy Act of 1994)
·
Jefferson Lab
Records Management Handbook, 2002
·
National
Archives and Records Administration (NARA) Disposition of Federal Records
·
NARA
General Records Schedule (a records management handbook)
·
DOE
Administrative & Scientific Records Schedules
·
ES&H Manual Chapter
5400 Appendix T2 Forms and Schedules:
o Records Inventory and Disposition
Schedule (RIDS) in the Jefferson Lab
Records Management Handbook.
o Records Log form is available
online.
o Records Disposition and Retrieval
(RDR) request form is available online.
o Jefferson Lab
General Records Schedule table of contents.
|
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ISSUING
AUTHORITY |
CHAPTER
AUTHOR |
APPROVAL
DATE |
EFFECTIVE
DATE |
EXPIRATION
DATE |
REV. |
|
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ESH&Q Division |
06/16/06 |
06/16/06 |
06/16/09 |
0 |
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