Fire/Safety Review Program

Policy

All University buildings shall be reviewed as required by relevant safety, health and environmental regulations. Reviews shall be conducted by representatives of Environmental Health and Safety.

Exception: Single family residential properties shall not receive fire/safety reviews. Laboratories shall be reviewed in accordance with the Laboratory Safety Review Program.

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Purpose

The purpose of the Fire/General Safety Review Program is to ensure the health and safety of faculty, staff, students and visitors while also ensuring compliance with appropriate regulatory agencies. At a minimum, key performance indicators identified in Fire/General Safety Review Program Key Performance Indicators shall be evaluated during each fire/general safety review.

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Authority and Responsibility

Environmental Health and Safety is responsible for:

  1. Developing a Fire/General Safety Review Program;
  2. Conducting annual reviews of all University buildings;
  3. Conducting follow-up reviews of all University buildings identified for re-inspections;
  4. Immediately stopping any work practices posing an imminent hazard to faculty, staff, students and visitors;
  5. Immediately contacting the work center for facility deficiencies posing an imminent hazard to faculty, staff, students and visitors;
  6. Providing written reports to the Facility Manager or building contact;
  7. Submitting work requests to Facilities Services or Physical Plant for building maintenance issues;
  8. Reviewing the Fire/General Safety Review Program to ensure that the program is in compliance with current codes and standards; and
  9. Ensuring corrective action is followed through identified concerns.

Facility managers or building contacts are responsible for:

  1. Complying with all aspects of the Fire/General Safety Review Program;
  2. Providing access to all areas and rooms under their responsibility;
  3. Coordinating corrective action with the appropriate department for any work practices identified as imminently hazardous in accordance with the University of Chicago’s Personnel Policy on Progressive Corrective Action, Section 703; and
  4. Addressing any concerns discovered during the fire/general safety review under their responsibility within 90 days.

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Frequency

Initial Review

All University buildings shall be reviewed annually. Safety concerns identified during the initial review shall be corrected within 90 days, unless a shorter period of time is specified due to the severity of concerns or a longer period of time is necessary because of operational considerations. Longer periods of time shall be agreed upon by Environmental Health and Safety.

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Procedure

University buildings shall be reviewed in accordance with the procedure set forth below:

  1. All fire/general safety reviews shall be unannounced;
  2. A representative from Environmental Health and Safety shall tour the building;
  3. When there is a need for additional information and/or clarification during fire/general safety reviews, the facility manager or building contact shall be notified;
  4. If any general areas are not accessible, the facility manger or building contact shall be notified and directed to provide access to all areas and rooms within the building; and
  5. Fire/general safety review results shall be provided to the facility manager or building contact within ten business days of a particular building’s review.

Each department shall ensure that corrective action plans have been implemented or are in process prior to the time frame listed on the Fire/General Safety Review for each concern.

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Imminent Hazards

Any work practices (e.g., using extension cords in or near water) or facility deficiencies (e.g., emergency eyewash not operating properly) posing an imminent hazard to faculty, staff, students and visitors identified during fire/general safety reviews shall be stopped and corrected immediately. The representative from Environmental Health and Safety who discovers any imminent hazard shall immediately notify the facility manager or building contact who is responsible for coordinating corrective action with the appropriate department. All imminent hazards shall also be noted in the inspection report.

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Progressive Resolution Process

University buildings failing to correct concerns identified on any inspection report shall be subject to the progressive resolution process. Each identified concern shall be corrected prior to the corrective action date. For concerns not corrected, the following action shall take place:

  • Stage One of Non-Compliance: A letter identifying the concerns not corrected shall be sent to the Department Head with a copy sent to the Department Head’s superior;
  • Stage Two of Non-Compliance: A letter identifying the concerns not corrected shall be sent to the Department Head’s superior with a copy sent to the Provost and Vice President for Administration/Chief Financial Officer; and
  • Stage Three of Non-Compliance: A letter identifying the concerns not corrected shall be sent to the Provost and Vice President for Administration/Chief Financial Officer.

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Outside Regulatory Agencies

Outside regulatory agencies and insurance representatives requesting to inspect University properties or review components of the safety program in order to determine compliance with regulations pertaining to fire, workers’ compensation, safety, health and environmental issues shall be directed to Environmental Health and Safety.

A representative from Environmental Health and Safety shall accompany the representative from the outside agency on all inspections conducted and facilitate the necessary corrective action plan.

These inspecting agencies include, but are not limited to, the following:

  • Occupational Safety and Health Administration (OSHA);
  • City of Chicago Bureau of Fire Prevention;
  • City of Chicago Building Department;
  • City of Chicago Department of Public Health;
  • Centers for Disease Control and Prevention (CDC);
  • Environmental Protection Agency (EPA);
  • Illinois Environmental Protection Agency (IEPA);
  • State of Illinois – Fire Marshal;
  • Fire Insurance Representatives; and
  • Workers’ Compensation Consultant.

Refer to the Useful References area of the website for links. The appropriate administrative department and the Office of Legal Counsel shall be advised of the inspection and copied on all inspection related data. Agency requests for inspection related records or data shall be directed to Environmental Health and Safety who will then clear the request with the Office of Legal Counsel.

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Trend Analysis

All key performance indicators shall be tracked in a database maintained by Environmental Health and Safety. This data shall be used for the purpose of trend analysis on a quarterly basis.

Reviewed: February 2016

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