ES&H Manual



5400 Documentation and Recordkeeping



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:


There may also be other program-specific documentation and/or recordkeeping requirements identified within your own work group.


2.0            Responsibilities


Text Box: NOTE:  These responsibilities pertain to ESH&Q-related material.


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   employee medical records,

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.


Text Box: Examples of regulatory programs where documentation and recordkeeping are or could be required include:
•	Air programs, under the US Environmental Protection Agency (EPA) Office of Air and Radiation,
•	Hazardous Wastes, under the Virginia Department of Environmental Quality (DEQ), and
•	Workplace Safety, under the DOE, which enforces DOE’s version of the Occupational Safety and Health Administration’s (OSHA) program.


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.


Text Box: Refer to ES&H Manual Chapter 2410 Appendix T2 Hazard Issues and Contractual Commitments Update Procedure for a detailed list of specific applicable standards that may have documentation and recordkeeping requirements.  The Subject Matter Coordinator and Subject Matter Experts, designated by Hazard Issue, are provided in ES&H Manual Chapter 2410 Appendix T1 Hazard Issues List.


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

·         employee exposure records

·         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        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        Hazardous Materials Transportation

·         radioactive material transfers

·         shipment of hazardous materials        Medical, First Aid, and Personal Injury Files

·         periodic medical tests

·         medical records tracking        Motor Vehicle Operation

·         accident files

·         reports


4.0            Program Requirements


Text Box: Jefferson Lab’s EMS documentation is organized into four documentation tiers, which are levels I, II, and III, and related documentation.  EMP-07 presents the means for controlling the writing, updating, and approving and managing Jefferson Lab’s EMS documentation.  For EMS-specific document control and recordkeeping procedures, refer to the EMS Plan, EMP-07, EMP-08, and EMP-13.


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.


Text Box: It is recommended that all documented material, including information that is not considered sensitive, be stored in a location suitable to protect it from fire, storm, or other damage.  It is also recommended that this information be duplicated (backed up on disk) and stored or filed in a separate location to protect it from fire, storm, or other damage.


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


Text Box: Formally retained records not having specified retention periods may only be destroyed with the approval of the Records Manager.


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


Text Box: Note that hard copy EMS documents maintained outside of the Document Control Matrix (EMP-07) are considered uncontrolled documents and are valid for only one week from when they are printed.


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.













ESH&Q Division

Stephen Smith






This document is controlled as an on line file.  It may be printed but the print copy is not a controlled document.  It is the user’s responsibility to ensure that the document is the same revision as the current on line file.  This copy was printed on 7/28/2009.