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K. Staff: Personnel, physicians, volunteers contract workers and students must follow established guidelines and procedures and: 1. Have the right to chemical use information with no resulting discrimination; 2. Will report all hazardous conditions and related injuries and illnesses to their Sutter Health contact. PROCEDURE A. The selection of all chemicals and chemical products is based on an evaluation prior to use by the department director/manager. This evaluation is to identify potential hazards,ensure that all necessary safety procedures are in place and comply with all applicable local, state and Federal laws and regulations. Any new chemicals will be added to the department chemical inventory via the 3E Website. It is strongly encouraged that,whenever possible, the substitution of non- or less hazardous chemicals be a normal part of the selection process for purchasing all products containing hazardous chemicals. B. All hazardous chemicals including chemotherapeutic agents and radioactive materials are used, handled, stored and disposed of according to the SDS, applicable laws, regulations and the manufacturer's recommendations. All medical wastes are segregated, stored in containers and storage areas. They shall be disposed of by a permitted hauler of rendered non-hazardous by proper sterilization techniques as approved by the California Department of Public Health (CDPH). C. The written program includes protocols for managing all regulated waste streams according to local, state and Federal requirements. Permits, licenses and manifests are kept on file by the Hazardous Materials Coordinator. D. Each department is required to maintain a current inventory list of all the hazardous chemicals used within the department. A master file is centrally located in the Nursing Supervisor's office and the inventory lists are supported with accompanying SDS which can be accessed through the 3EOnline Website .3EOnline.com, the Sutter Valley Area intranet portal or Poison Control. E. Periodic environmental chemical and ventilation evaluation assessments and monitoring are conducted in accordance with applicable laws and whenever necessary to assure that employees will not be adversely affected by hazardous materials, gases or vapors in the workplace. Monitoring frequency is based on the results of initial monitoring, the definition of the potential hazard that could be present, and the accuracy of the monitoring method and the likely variability of the exposure. Monitoring test results are available to the employees upon request. If results exceed the action level, immediate control methods are implemented, monitoring repeated and employees notified as may be required. In addition,the Radiation Safety and Protection Program is overseen by the Radiation Safety Committee which is led by the Radiation Safety Officer(RSO). Radiation exposure monitoring is managed under a separate program (Title 17) that is overseen by the RSO. This group's goal is to make every reasonable Hazardous Materials and Waste Management Page 4 of 9 C.00