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2. Organisation of radiation safety

Responsibility for radiation safety begins with the individual handling radiation sources in his or her laboratory. It extends upwards, through a chain comprising the Responsible User (see Section 2.5), the Radiation Safety Officer (see Section 2.4), Environmental Health & Safety (see Section 2.11) and the Radiation Safety Committee (see Section 2.3). Services relating to radiation protection (e.g. monitoring, waste disposal) are provided centrally and are described in Sections 2.11, 5.3 and paragraph 8.3.2.

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2.1 ORGANOGRAM

At McGill University, the radiation safety program is a service provided by Environmental Health & Safety (EHS). In radiation safety matters, the EHS reports to the Vice-Principal, Administration and Finance. For a visual description, consult the attached organogram (see Appendix A).

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2.2 RADIATION SAFETY POLICIES

2.2.1 Compliance Enforcement Policy

The Canadian Nuclear Safety Commission has issued McGill University a Consolidated Radioisotope License for the possession, use and importation of radioactive prescribed substances or devices containing radioactive prescribed substances.

A Consolidated Radioisotope License is a single broad-scope license issued by the CNSC to an institution having many users of radioactive materials who are primarily in one location. The application for an issuance of a consolidated license to an institution rather than to each individual radioisotope user emphasizes to the institution its responsibility for a radiation safety program.

Upon issue of this licence the university assumes the responsibility to ensure that any use of radioactive prescribed substances on campus complies with the CNSC Regulations, Transport Packaging of Radioactive Materials Regulations, as well as twenty separate conditions that apply to the Radioisotope Licence.

The CNSC requires the following three components are in place:

  1. University Laboratory Safety Committee (ULSC)
  2. Radiation Safety Officer
  3. Radiation Safety Manual

Although the Radiation Safety Officer is responsible for the day-to-day operations of radiation safety services, he/she reports to the Operations Manager of Environmental Health & Safety (EHS)and to the University Laboratory Safety Committee. It is the Committee that has the authority to implement and enforce the radiation safety policy encompassing the acquisition, use, handling, storage and disposal of radioactive materials. The University Laboratory Safety Committee is appointed by and accountable to the Dean of Graduate Studies and Vice-Principal (Research).

The institution is visited annually by CNSC compliance inspectors to ensure that the above regulations and conditions are being met by radioisotope users. The CNSC has the ultimate authority to withdraw radioisotope user privileges if violations are observed and this could affect all those who use radioisotopes under McGill University's Consolidated Radioisotope License.

Following numerous CNSC compliance inspections, the University was directed to implement a policy for categorizing and responding to instances of non-compliance that are identified during inspections conducted by Environmental Health & Safety.

It is our hope, given the overall respect for radiation safety by McGill University users, that this policy will never have to be activated.

2.2.2 Radiation Safety "3 Strikes" Enforcement Policy

The Radiation Safety Officer and Technicians will visit each lab to which an Internal Permit is issued, at least annually, with a follow-up visit. The visit will be announced and at times unannounced for the follow up inspections. A compliance checklist approved by the University Laboratory Safety Committee will be used. All offences (major or minor) will be categorized as Radiation Safety Infractions.

A major offence would result from violations that pose immediate risk or danger to safety, health, release to the environment of reportable quantities, doses of substantial amount to staff, or place the CNSC Consolidated Radioisotope License in jeopardy. Examples of a major offence would include:

  • contamination above licence criteria;
  • inadequate monitoring program;
  • use or storage of food or drink in the laboratory;
  • inadequate training of new staff;
  • non-participation in required bioassay programs;
  • inadequate and/or unsafe work and storage areas for radioisotopes; and
  • inadequate and/or unsafe storage areas for radiation waste.
  • inadequate signage;
  • inadequate posting (internal radioisotope permit, CNSC posters);
  • inadequate inventory records;
  • inappropriate use of warning labels; and
  • inappropriate segregation and/or identification of radiation waste for disposal or decay.

Each infraction will be reported as a strike and additional strikes will be granted if the same problem has not been corrected during the follow-up visit. If this has been done, then the strike will be removed. This policy is explained as follows:

Strike 1
Radiation safety infraction is observed and recorded by radiation safety personnel. The Radiation Safety Officer specifies compliance and reply deadline and informs Permit Holder by way of copy of inspection report or memorandum.

Strike 2
Permit Holder has not replied within due date or the same infraction is observed during the follow up inspection. The Radiation Safety Officer revises the deadlines and informs the EHS Operations Manager and the Chair of the University Laboratory Safety Committee of the situation.

Strike 3
The Radiation Safety Officer performs follow up inspection and observes the same infraction is still not corrected after the compliance deadline. She/he informs the Operations Manager, Department DRSO, and the Chair of the University Laboratory Safety Committee. The Chair of the University Laboratory Safety Committee advises the Permit Holder of sanctions. Sanction options include suspension of purchasing privileges or outright suspension of Internal Permit and confiscation of radioactive materials by radiation safety personnel.

2.2.3 Radioisotope Laboratory Decommissioning Policy

If a professor or researcher vacates a laboratory or discontinues work with radioactive material it is necessary to decommission the laboratory. The CNSC requires that a record of inventory disposition be forwarded to the Radiation Safety Officer as well as wipe test and/or radiation monitoring results.

Decommissioning certifies that the laboratory is free of radioactivity or radioactive surface contamination. This is achieved when wipe test results are less than 0.5 Becquerels per square centimetre (Bq/cm2) for all radioisotopes, with the exception of alpha emitters where the value is set at less than 0.05 Bq/cm2.

It is recommended that the decommissioning be performed by the researcher leaving the laboratory or ceasing radioisotope work, if not, it will be done by the Radiation Safety Officer and the department will be charged for the service.

2.2.4 Radiation Safety Training Policy

All new staff or students asked to work with radioisotopes must complete radiation safety training at McGill University. This requirement can be waived if, records of training from a recognized institution are provided. However, the Radiation Safety Officer will assess the level of knowledge; if the evaluation proves to be unsatisfactory then training will be recommended. A major offence will be issued to the Internal Permit Holder, if an individual with insufficient knowledge does not attend a training session.

The McGill University Laboratory Safety Committee requires that all users of radioisotopes or radiation emitting equipment be trained in safe radiation work practices and procedures. Clerical personnel, including cleaners, maintenance staff and security agents, who work in areas where radiation is used are required to undergo basic radiation safety awareness training.

Training must be given prior to the use of radiation materials or equipment. Users can attend radiation safety courses at McGill University or from other recognized institutions. For more information on radiation safety courses contact the Environmental Health & Safety.

2.2.5 McGill Radioisotope Acquisition Policy

To acquire radioisotopes at McGill University, users must possess an up to date Internal Radioisotope Permit (see Section 4.2) issued by Environmental Health & Safety. The user can then use the McGill Marketplace portal and myLab McGill Tracking System to purchase radiation materials from PerkinElmer Life Sciences, Amersham Biosciences or from other suppliers. For details see Section 4.4.

2.2.6 Pregnancy & Breast-Feeding Policy

The first trimester is known to be the most radiosensitive time for a foetus, thus, it is beneficial, but not required, to meet with the Radiation Safety Officer (RSO) as soon as possible to review safety practices and monitoring options. The policy covers not only the pregnancy period of the employee but also the breast-feeding months.

It is up to the pregnant radiation worker to decide whether or not she will formally declare her pregnancy to the RSO.

She may choose to declare her pregnancy to the RSO. Then, the RSO will meet with the pregnant worker to review radiation safety procedures, the risk to the foetus, and the guidelines outlined in the Nuclear Safety and Control Act and in the Commission de la Santé et Sécurité au Travail (CSST) document "Safety Working Conditions for a Safe Maternity Experience - Guide for the Pregnant or Breast-Feeding Worker".

She may choose not to declare her pregnancy to the RSO. In this case, only the radiation limits for adult radiation workers will be in effect, not the limits for the foetus. Undeclared pregnant workers are considered as protected under the regulations for adult Radiation Users. However this does not apply for Nuclear Energy Workers (NEWs).

All female radiation workers of childbearing age can request at any time a copy of the CSST document from the RSO as part of the process of becoming a trained radiation worker.

For more information on this topic, see Sections 3.5 and 3.8.

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2.3 RADIATION SAFETY COMMITTEE

The Radiation Safety Committee has been merged and is now part of McGill's University Laboratory Safety Committee. Information concerning its mandate, members, minutes, agendas and schedules can be found on EHS Lab Safety Committee page.

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2.4 RADIATION SAFETY OFFICER

The Radiation Safety Officer (RSO) is the executive officer of the University Laboratory Safety Committee (ULSC). The RSO is the individual designated by the University Administration (the licensee) to manage the radiation safety program in accordance with the Nuclear Safety and Control (NSC) Act and Regulations and the specific conditions of the consolidated radioisotope license. The RSO must be a competent, adequately trained and a sufficiently experienced individual with the resources, authority and time to fulfil the mandate. The lines of communication between the RSO and the university administration must be direct enough to ensure adequate implementation of all aspects of the radiation safety program.

2.4.1 Duties of the RSO with Respect to the Institution

The Radiation Safety Officer shall:

  • act as the chief liaison officer between McGill University and outside authorities, such as the Canadian Nuclear Safety Commission (CNSC), Health Canada, Radiation Protection Bureau, Bureau of Radiation and Medical Devices, National Dosimetry Services and the Commission de la Santé et de la Sécurité du Travail (CSST) du Québec, in all matters relating to radiation safety;
  • monitor compliance with radiation safety procedures described in this manual;
  • ensure satisfactory provision of the services described in Sections 2.11 and 8.3 of this manual and to institute other services when required;
  • ensure the preparation and dissemination of information on radiation safety;
  • develop and provide application forms for internal radioisotope permit applications and information bulletins and guidelines for those requesting such material;
  • ensure appropriate radiation protection training is provided for all users and those who come into contact with radioactive materials or radiation producing equipment (i.e. cleaning staff, maintenance people);
  • maintain the Internal Permit management system and keep records of all related information, including: lists of Permit Holders, Nuclear Energy Workers (NEW), radiation users, and areas where radioactive sources or radiation emitting devices are stored or used;
  • ensure that each Internal Permit is amended when necessitated by changes to facilities, equipment, policies, radioisotopes, procedures or personnel;
  • establish, implement and maintain a safety control and assessment program in conjunction with the Laboratory Safety Committee;
  • systematically and periodically review survey data for radiation and contamination levels in all areas where radioactive materials are used, stored or disposed;
  • implement a personnel monitoring program including bioassay (i.e. thyroid monitoring) where applicable;
  • review occupational radiation exposures and recommend ways of reducing exposures in the interest of the ALARA (As Low As Reasonable Achievable) principle;
  • conduct and/or supervise decontamination and decommissioning procedures;
  • certify decommissioned laboratories as being free of contamination;
  • investigate all accidents, losses of radioactive materials and overexposure reports and advise the Canadian Nuclear Safety Commission;
  • provide waste disposal procedures in accordance with conditions of the radioisotope license;
  • ensure leak testing of sealed radioactive sources;
  • control the acquisition, use and disposal of radioactive materials through the issuance of Internal Permits;
  • organize transportation of radioactive materials outside University premises if required; maintain required Canadian Nuclear Safety Commission (CNSC) records;
  • co-ordinate the development of radiation emergency plans;
  • review and submit plans for construction or renovation of radioisotope laboratories to the CNSC for approval;
  • conduct routine maintenance and calibration of any radiation detection equipment; and maintain a list of the forms and records, for which the RSO is responsible.

2.4.2 Duties of the RSO with Respect to the Laboratory Safety Committee

The Radiation Safety Officer shall:

  • propose to the Laboratory Safety Committee any amendments to the Radiation Safety Policy Manual;
  • prepare and submit summaries of radiation safety services and the results of inspections, follow ups and decommissioning projects; and
  • prepare, in consultation with the Laboratory Safety Committee, an annual report to the Canadian Nuclear Safety Commission as required by Regulatory Document R-80 and the Consolidated Radioisotope License, condition 20;
  • present information on accidents, incidents or releases of radiation.

2.4.3 Departmental Radiation Safety Officer (DRSO)

As a measure to improve radiation safety, a department may choose to appoint a Departmental Radiation Safety Officer (DRSO). This individual will be a full time, permanent faculty or technical staff member who would assume certain functions on behalf of the department head as presented in the DRSO mandate shown below:

  • Act as the department head's designate in radiation safety matters pertaining to the department Maintain liaison with University RSO on all radiation safety matters pertaining to the department.
  • Act as substitute, if department Permit Holders are not available.
  • Manage common laboratory rooms where radioisotopes are used.
  • Oversee department radiation storage and usage locations to ensure they are safe and secured.
  • Oversee department radiation waste areas to verify they are adequate, neat and in accordance with radiation safety practices and policies.
  • Coordinate departmental radiation safety programs such as coordinating for dosimetry subscription services, and monitoring proper storage of dosimeters.

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2.5 PERMIT HOLDERS

A Permit Holder is an individual responsible for the safe procurement, storage, use and disposal of specific radiation sources. He/she is usually in charge of research or teaching operations and is responsible for the safe usage of these sources. In particular, a Permit Holder must:

  • Work according to the practices stated in the Canadian Nuclear Safety Commission (CNSC) Safety Poster for Basic-Level, Intermediate-Level and High-Level laboratories.
  • Adhere to conditions stated in the internal radioisotope permit.
  • Follow the rules and regulations set out by CNSC and the McGill University Laboratory Safety Committee.
  • Post a no food and beverage sign, up-to-date internal radioisotope permit, CNSC Safety poster and laboratory information card, visible to all lab occupants.
  • Place radiation warning signs identifying radiation work areas.
  • Provide adequate facilities, equipment and supervision to ensure that workers or students follow the rules and regulations set out by the CNSC and the McGill University Laboratory Safety Committee.
  • Maintain an up-to-date inventory of radiation sources including the locations where they are installed, stored, handled, applied or disposed (see Appendix J).
  • Establish working procedures and emergency measures, and post them where required.
  • In co-operation with the Radiation Safety Officer, designate personnel as Radiation Users or Nuclear Energy Workers and maintain lists of such personnel.
  • Ensure that all Radiation Users and Nuclear Energy Workers under their jurisdiction receive adequate instruction in the safe handling of the radiation sources and radiation-emitting equipment commensurate with their duties. Also, ensure that each of these workers reads and understands the relevant sections of The Manual and signs a declaration to this effect (see Appendix I).
  • Supply Environmental Health & Safety with all information needed for licensing or Internal Permit purposes.
  • Allow only authorized persons to enter areas designated for radiation use and to get access to radiation materials.
  • Provide special instruction and/or precautionary measures for students, clerical personnel and others who are authorized to enter or work in areas where there is a possibility of radiation exposure, but who are not classified as Radiation Users or Nuclear Energy Workers.
  • Report incidents of loss or theft involving radioactive material to the Radiation Safety Officer.
  • Maintain area monitoring and/or wipe test records for inspection by the Radiation Safety Officer.
  • Ensure that, when required, personnel wear assigned radiation monitors throughout the working day. The Permit Holder must also keep records of the dose received by each person and, in co-operation with Environmental Health & Safety, investigate any excessive or abnormal dose.
  • Ensure that, when required, personnel make themselves available for bioassay procedures such as thyroid monitoring and that adequate records of the results of such procedures are maintained.
  • Institute, where appropriate, additional safety precautions and/or monitoring procedures for pregnant Nuclear Energy Workers (NEWs) and, where necessary, re-arrange the duties of pregnant NEWs (see Section 3.5). These functions can be performed with the assistance of Environmental Health & Safety.
  • Maintain and centralize all required documents and/or records in the McGill Radiation Log Book to facilitate consult by the CNSC inspector and the RSO.

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2.6 CLASSIFICATION OF RADIATION WORKERS

For the purpose of organizing radiation safety in McGill University, persons falling within the jurisdiction of this Manual are classified as:

  • Nuclear Energy Workers. This is a term legally defined by the NSC Act (see Section 2.6.3).
  • Radiation Users. This term has no legal status but is used to define individuals who need not be legally classified as Nuclear Energy Workers but who nevertheless require a range of protective measures because they are in regular proximity to radiation sources (see Section 2.6.2).
  • Other Personnel. This group includes visitors and members of the public (see Section 2.8).

2.6.1 Radiation User Definition

At McGill University, an individual is classified as a "Radiation User" if he or she:

  • regularly uses or handles radiation sources such that he/she could receive a measurable annual radiation dose-equivalent less than 1 mSv (100 mrem) above the background level; or
  • works in an area where radiation sources are used, such that, even though he/she does not himself/herself work with the sources, he/she could receive a measurable annual radiation dose-equivalent less than 1 mSv (100 mrem) above the background level.

N.B. This definition has implications for non-radiation workers in adjacent areas (see Section 3.6).

Permit Holders must designate those members of their staff, or other persons working in their laboratories or departments, as Radiation Users if they satisfy either of the above requirements. In the case of personnel designated under the second option, the decision should be made in co-operation with the Radiation Safety Officer, who will advise on the working conditions of the persons concerned. Borderline cases should be referred to the Radiation Safety Officer.

2.6.2 Radiation User Responsibilities

A Radiation User is required to:

  • study the relevant sections of The Manual, as listed by the Permit Holder, and sign a declaration that he/she has understood the meaning and implications of these sections (see Appendix I);
  • be familiar with the particular radiation safety procedures in his/her work and work area, and conduct his/her work accordingly; and
  • wear a personal radiation monitor or monitors, if required to do so by the Permit Holder.

In the case of a female Radiation User, she is required to notify her immediate supervisor or the Permit Holder, when she knows or suspects that she is pregnant. Subsequent to notification, McGill may institute personal monitoring (external and/or internal), or increase its frequency or scope, to limit the exposure of the foetus to radiation. These arrangements can be made with the Radiation Safety Officer, who will conduct a thorough workplace inspection for the pregnant radiation user in question. However, since the annual dose-equivalent received by the Radiation User is usually below 1 mSv (100 mrem), and this is well below the permitted limit for the foetus (see Section 3.5), re-assignment of duties is not normally required for female Radiation Users who become pregnant.

N.B. Routine monitoring of a Radiation User is not mandatory unless he/she is likely to receive an annual dose-equivalent in excess of 1 mSv (100 mrem), in which case he/she will be designated as a Nuclear Energy Worker (see Section 2.6.3). However, it is a useful precaution to monitor Radiation Users so as to confirm that they do in fact remain below this limit. The exact monitoring procedure will depend on the type of work undertaken by the individual concerned.

2.6.3 Nuclear Energy Workers

In special circumstances, persons may be classified as a Nuclear Energy Worker (NEW) as defined in the NSC Act. A Nuclear Energy Worker is defined by the NSC Act as: "a person who is required, in the course of the person's business or occupation in connection with a nuclear substance or nuclear facility, to perform duties in such circumstances that there is a reasonable probability that the person may receive a dose of radiation that is greater than the prescribed limit for the general public."

The dose limit referred to in the definition is 100mSv (10000 mrem/5 years) per year. Each Permit Holder must, in co-operation with Environmental Health & Safety, designate as Nuclear Energy Workers those persons who appear to satisfy the above definition. Each case will be individually reviewed.

In addition to the obligations assumed by all Radiation Users, as set out in Section 2.6.2 above, a Nuclear Energy Worker must:

  • Read and sign the "Notification of Nuclear Energy Worker Status" form (see Appendix M);
  • undergo medical surveillance if required (see Section 5.6);
  • be subjected to mandatory routine personnel monitoring of a type appropriate to the work undertaken; and
  • if so requested by the Canadian Nuclear Safety Commission, a Permit Holder must, within 10 days or an exposure incident, supply the Commission and the Radiation Safety Officer with an estimate of the "committed dose" resulting from possible ingestion of unsealed radionuclides by the Nuclear Energy Worker (see paragraph 3.4).

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2.7 STUDENTS

The following guidelines apply to students (eg. undergraduate, graduate and post doctorates) who participate in classroom demonstrations, laboratory courses or research projects involving the use of radioactive sources or radiation-emitting equipment.

It is important to instil a proper attitude towards radiation sources, i.e. respect for potential hazards and the need for safe handling procedures, but without undue and unnecessary fear. The instructor must therefore set a good example.

An undergraduate student who undertakes a major research project and regularly uses radiation sources should be classified as a Radiation User (see Sections 2.6.1 and 2.6.2).

An undergraduate student participating in classroom demonstrations, laboratory courses and/or projects utilising low-level radiation sources, or working in an area where radiation sources are used or installed but does not himself/herself use these sources, is not normally classified as a Radiation User. Rather, undergraduate students should be classified as a non-radiation worker and subject to the general public limit of 1 mSv (100 mrem) per annum (see Sections 3.6 and 3.8). In view of this, no single demonstration or laboratory experiment should carry the likelihood of an exposure to a student exceeding one-tenth of the general public limit, i.e. exceeding 0.1 mSv (10 mrem). In practice, this limitation does not impose any unreasonable constraint on the conduct of laboratory demonstrations or courses.

Personal monitoring of individual students is not required. In fact no additional precautions are needed for students over the age of 18 if the limits suggested are followed.

In exceptional circumstances, an undergraduate student may undertake work that would require him/her to be classified as a Radiation User or Nuclear Energy Worker. Each case must be submitted to the Radiation Safety Officer for approval.

A graduate student who regularly uses radiation sources should be classified as either a Radiation User or a Nuclear Energy Worker, as appropriate.

The Permit Holder, in co-operation with Environmental Health & Safety, must:

  • conduct a complete radiation survey of the working area to be used by undergraduate students; and/or
  • conduct a review of the doses likely to be received by these students during the procedures to be undertaken, to ensure compliance with Section 2.6.1 above.

When students, including graduate students, are required to handle radiation sources or to work with radiation-emitting equipment, adequate instruction must be given prior to the actual usage of the sources and suitable monitoring must be undertaken.

Particular care must be taken when: (a) students handle unsealed radioisotopes, and (b) any student is under the age of 18.

No student should undertake work involving the handling of radioactive sources or radiation-emitting equipment, when he/she is alone in the laboratory or department (see also Section 2.10).

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2.8 OTHER PERSONNEL

Non-radiation workers may have access to areas where radiation sources are stored or used, for several reasons:

  • Clerical, maintenance & custodial personnel or other non-scientific staff may require access regularly or occasionally. Such access should be permitted only when the sources are in a "safe" condition, i.e. radioactive sources are in a shielded storage container and radiation-emitting equipment is "off". It is important to explain these rules clearly to the staff involved and, particularly for cleaning staff, to demonstrate the safe condition of the area when all sources are in storage or "off".
  • Occasionally, laboratory staff not regularly handling radiation sources may be asked to participate in a procedure involving radiation. Such persons should be treated as "students" and the guidelines of Section 2.7 should be applied.
  • Visitors should be regarded as non-radiation users but if they are taken into areas where radiation sources are in use they may be issued radiation monitors on a temporary basis. This applies if there is a possibility of their receiving a measurable radiation dose during the visit.

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2.9 ACCESS TO LABORATORIES AND WORKSHOPS

Access to McGill laboratories, workshops and other work areas housing hazardous materials (example: radioactive materials) or machinery is limited to McGill staff and students or other persons on official business (example: CNSC or other Government inspectors). Steps should be taken to ensure that those entering any of these areas are adequately protected from hazards and informed about the safety and emergency procedures relevant to their activities.

Other people, in particular young children, are not permitted in hazardous work areas with the exception of University sanctioned tours and visits, for example McGill Open House. In these instances, careful supervision must be exercised.

Laboratory facilities where nuclear substances are used and/or stored must be attended or locked at all times.

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2.10 AFTER-HOURS WORK

Working alone is considered an unsafe practice at any time. If however, the nature of your work makes it unavoidable, measures should be taken to ensure that others are aware that you are doing so and to have someone check in with you from time to time, either in person or by telephone.

  • For authorisation to enter buildings after hours, inform your Building Director who will provide your name to the Security Services.
  • Ensure that you carry a McGill ID card at all times.

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2.11 ENVIRONMENTAL HEALTH & SAFETY

Environmental Health & Safety (EHS) has the mandate to plan, organize, co-ordinate and implement University programs in occupational health and safety in conformity with applicable laws, regulation, codes and standards.

The objectives of the EHS are to establish and maintain a high standard of safety in all University activities, to recognize and minimize occupational hazards and to prevent accidents and injuries of all kinds. The principal functions of the EHS are:

  • To provide information and training to McGill staff and students in matters related to occupational health and safety.
  • To perform specialized measurements and assessment of occupational hygiene.
  • To serve as liaison between the University and certain regulatory agencies like the CNSC and the CSST (Commission de la Santé et de la Sécurité du Travail du Québec).