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J. Department Managers/Directors will purchase and provide the appropriate PPE and training for their employees who handle hazardous materials. The selection of PPE is based on information in the SDS and the PPE policy and procedure. K. Reporting and investigating all hazardous materials or waste spills, exposures and other incidents is accomplished via inspection reports, audit reports, Hazardous Chemical Spill Report Form, and drill critiques: 1. General EOG rounding inspections include surveillance of hazardous material storage areas/ containers, appropriate labeling, etc. 2. Audits of the Hazardous Materials and Waste Management Program are conducted on an annual basis. Results are reviewed and corrective action taken by the hazardous waste coordinator or Environment of Gare Committee. 3. The department manager/director completes the incident reports. They are reviewed and appropriate corrective action is taken as deemed necessary to ensure a safe environment pertaining to hazardous materials and waste management. 4. Pre -assigned staff completes the hazardous material drill critiques. All critiques are reviewed and any deficiencies noted are addressed. L. All contractors shall be compliant with all regulatory requirements regarding their responsibilities when using, storing and disposing of hazardous chemicals while on affiliate owned or leased property. M. Each department will develop and maintain department -specific Spill Response Procedures for the hazardous materials used in and owned by their department based on the SDS information and utilizing the Safety/Isolate/Notify (SIN) acronym. Department managers will ensure, through documentation, that employees are trained and familiar with their department specific response procedures. These procedures include specific precautions, procedures and PPE. All employees are trained to respond to incidental and minor spills. If a major spill occurs, a "Code Orange" will be initiated and the HazMat Coordinator will be contacted to facilitate a response. If outside assistance is needed to clean up a hazmat spill beyond the capability of the department or affiliate: • Clean Harbors Emergency Response Line 800-645-8265 • Atlas Environmental 866-547-2857 • Stericycle 866-783-7422 1. Any employee exposed to a hazardous material or waste should report for proper medical treatment immediately, complete an electronic Report of Injury and report the incident to Employee Health, manager or the Nursing Supervisor, N. Construction: During pre -construction meetings, information is exchanged with contractors regarding their responsibilities when using, storing and disposing of hazardous chemicals while on affiliate owned or leased property. All contractors shall be compliant with all regulatory requirements. Contractors bringing hazardous materials onto Sutter Health property are required to have current SDS present at the job site at all times. In the event of a spill beyond the capabilities of the contractor's cleanup abilities, the contractor must contact the hospital Operator and call a "Code Orange" and notify the affiliate contact immediately. O. Radiation Safety: The Radiation Safety Protection Program exists to provide for a safe physical environment through programs for radiation protection, monitoring, accident procedures and education which permit the clinical use of ionizing radiation sources. Hazardous Materials and Waste Management Plan. Retrieved 3/16/2022. Official copy at http://sh-s[ch.policystatcom/policy/ Page 6 Oi 8 10532958/. Copyright ©2022 Sutter Tracy Community Hospital