2017-119 Audit Scope and Objectives
California State University—Health and Safety Compliance
The audit by the California State Auditor will provide independently developed and verified
information related to the health and safety compliance of the California State University (CSU)
Channel Islands, Sacramento, San Diego, and Sonoma campuses, and will include, but not be limited
to, the following:
- Review and evaluate the laws, rules, and regulations significant to the audit objectives.
- For the four selected CSU campuses, determine whether the campuses have adequately defined
roles and responsibilities for employee and student safety by determining the following for each
- Whether the campus has a Chemical Hygiene Committee and a Joint University Safety
Committee in accordance with state or federal regulations. Also, determine how often these
committees meet and whether minutes are taken and made available to employees upon
- Whether the roles and responsibilities for the Chemical Hygiene Officer, Laboratory
Supervisors, and Principal Investigators are clearly defined, documented, and readily
available to ensure worker safety.
- Whether the campus has a biosafety committee. If not, assess the appropriateness of not
having such a committee.
- Whether the campus has qualified radiation and laser safety officers. If not, assess the
appropriateness of not having such officers.
- For the four selected campuses, determine whether the campuses ensure adequate availability
of safety equipment and monitor the proper operating conditions of such equipment.
Specifically, determine the following for each selected campus:
- The extent to which the campus provides and requires proper personal protection
equipment (e.g. lab coats, goggles, gloves, face masks, shields, etc.) and engineering
controls (e.g. air filters, fume hoods, snorkels, etc.). Determine how often the engineering
controls are checked to ensure effectiveness and adequacy for current working conditions
and the average replacement and repair time for such equipment.
- Whether appropriate fire extinguishers, suppression systems, eye wash, emergency
showers, and other safeguards are readily available, sufficient for current working
conditions, and routinely checked to ensure proper operation.
- How often, and to what degree, the campus monitors air quality and checks ventilation
systems where chemicals are stored and where technicians are near chemicals (e.g.
stockrooms, employee offices, classrooms, hallways, storage facilities, etc.). Also, assess the
method, the frequency, and the extent to which biosafety hoods and autoclaves are
inspected and certified.
- For the four selected campuses, determine how each campus' procedures and practices for
proper storage and safety of equipment ensure the following:
- Whether the campus adequately maintains controlled chemicals (e.g. flammable, acid,
poison, gas, corrosives, etc.) with appropriate certifications and permits for every location
where chemicals are maintained. Also, assess the adequacy of safeguards put in place to
prevent unauthorized access to laboratories and storage locations where chemicals are
- Whether the campus has properly labeled radiation sources. Also, determine whether the
campus follows appropriate procedures to ensure that employees who access radiation
sources are properly monitored in accordance with applicable laws and regulations.
- For the four selected campuses, assess the adequacy of each campus' safety program and
student and employee access to information and training by determining the following:
- The extent to which employees have access to appropriate information for compliance with
California Hazard Communication regulations or other applicable laws, Safety Data Sheets,
standard operating procedures, and where this information is located.
- How and the extent to which the campus provides annual notifications for lead based paint,
asbestos, and other carcinogens to campus employees and students. Also, assess whether
areas containing lead, asbestos, and other carcinogens are properly marked.
- Whether the campus has clearly defined the roles and responsibilities of individuals in
charge of campus protocols and training for the clean-up of incidences such as chemical
spills, dead rodents, mice contamination, bodily fluids, needles, and syringes. Also,
determine how the scope of the training is established.
- Whether the campus has a respiratory protection program and whether the program is
designed to adequately protect employees and students.
- Whether the campus has a written blood pathogen program and radiation and laser safety
program. Also, determine whether the campus has made employees aware of these
programs and the extent to which training and competency of employees in these programs
- Whether the campus had adequate policies, protocols, and practices for training and
supervising students on the hazards of the laboratory. Also, determine whether students
and employees are provided safety training prior to working in the laboratories and are
adequately supervised while working in teaching and research labs.
- Whether the campus has an ongoing training for quarantine procedures in the event of an
outbreak of disease on campus.
- For the four selected campuses and the CSU Chancellor's Office, assess the monitoring of
compliance with health and safety laws, regulations, policies, and procedures by determining
- Whether the campus performs self-audits in teaching and research laboratories that use
potential hazardous chemicals and equipment. If the campus does not perform self-audits,
assess its reasons. If the campus performs self-audits, assess the following:
- The appropriateness of the frequency of these self-audits.
- The appropriateness of the frequency of audits performed by the campus'
Environmental Health and Safety Office in the areas that use chemicals and equipment
to ensure compliance. If no such audits are performed, determine why.
- Whether the CSU Chancellor's Office and campus Environmental Health and Safety Office
have sufficient authority to require compliance with all applicable health and safety
- The enforcement actions levied against the CSU Chancellor's Office and the campuses for
health and safety violations during the past five years and the agencies that issued such
- Identify the circumstances and the timeline surrounding when administrators at CSU
Sacramento became aware of unsafe levels of lead in the campus drinking water and when the
campus community was informed of this hazard. Assess the reasons for any delays in informing
the campus community.
- Administer a survey to the laboratory Instructional Support Assistants and Technicians of each
CSU campus to get a general overview of the health and safety climate at the campuses and to
receive staff perspective on laboratory conditions and compliance with existing laws and
- Review and assess any other issues that are significant to the audit.