(1) The purpose of this Procedure is to ensure Southern Cross University (SCU) management, employees, students and others are aware of the risks associated with Scheduled Substances and Other Poisons (collectively, Substances) in the workplace and relevant management strategies for the risk mitigation process. (2) All employees, students, and others must follow this Procedure. (3) This Procedure applies to all SCU Work Units and sites. (4) Scheduled Substances and Other Poisons descriptions (5) Work Units using Substances must develop, implement and maintain a Substances Management Plan (SMP) to ensure Substances are managed and used safely. If it is a scheduled substance, a sub-management plan is required. (6) The SMP prepared by the Work Unit must contain the elements in this section to describe how Substances are managed and is to include: (7) Further guidance for preparing an SMP is available at QLD Gov Guidance SMP (8) A checklist to assist in preparing an SMP is available at SMP Checklist (9) If a Work Unit already has a chemical management system or related risk management documentation in place containing all the information required in this Procedure and in accordance with legislative requirements, then this existing documentation can be referred to collectively as the SMP. (10) The SMP must: (11) The SMP must state the governance arrangements that ensure accountability for compliance with the SMP. Governance arrangements must include details relating to: (12) The SMP must include the following operational details: (13) The SMP must be reviewed in accordance with section 68 of the Poisons Regulation (QLD). For section 68, a review incident means any of the following: (14) Work Units must appoint a “Responsible Person” who will be responsible for developing the SMP and ensuring it is compliant with the relevant Acts, Regulations and SCU requirements. (15) The Responsible Person will be a person authorised by the Head of Work Unit to monitor the use and storage of Substances. They are also the person who applies for government authorisations/permissions on behalf of an Applicant. (16) The SMP must be prepared following a risk assessment, identifying the risk of physical or chemical reaction of Substances and what reasonably practicable steps will be implemented to eliminate or minimise that risk. (17) The Head of the Work Unit must ensure the SMP and risk assessment is regularly reviewed and assessed. (18) The SMP must state the: (19) The SMP must also state the process for ensuring all Substances are labelled and in closed containers. (20) The SMP must state: (21) The SMP must state the minimum training and/or competency level of all personnel who will use, handle and/or have dealings with Substances, including ongoing training to maintain skills and knowledge. (22) The SMP must state the appropriate level of supervision when using, handling, or dealing with substances. (23) All workers and students who are expected or may come in contact with or use Substances as provided under this procedure will be provided with training on the SMP and appropriate storage, use and handling of the Substance. (24) The SMP must describe procedures for ensuring that only appropriately authorised persons buy Substances. (25) The SMP must include a description of how Substances will be stored to prevent contamination. Such descriptions should consider: (26) The SMP must describe procedures to ensure an ignition source is not introduced into an area where flammable Substances are being used if there is a possibility of fire or explosion. (27) The SMP must list the suppliers of the Substances and record evidence that the Suppliers have appropriate authorisations to supply. (28) The SMP is to include details on how a drugs/poisons register is to be prepared, updated, audited and reviewed. Requirements for registers vary between NSW and QLD jurisdictions. (29) (23)Restricted S7, S8, S9 and S10 Substances within the scope of this Policy and Procedure are to be recorded in a drugs/poisons register. The registers may be electronic or paper based and must include details (e.g. date, name, form, strength and amount of poison, nature of dealing) to be able to reconcile the amount of poison received, applied, supplied or disposed of. (30) For QLD workplaces - A poisons register, which records all dealings in relation to high-risk poisons (Restricted S7, S8, S9 and S10), must be established by the work unit. “Other Poisons”, as defined by this procedure, are also to be recorded in a register. The poison register may be electronic or paper based and must include details (e.g. date, name, form, strength and amount of poison, nature of dealing) to be able to reconcile the amount of poison received, applied, supplied or disposed of. Information about the requirements for a poisons register is in Page 15, Subdivision 2 High-risk poison register of the QLD Medicines and Poisons (Poisons and Prohibited Substances) Regulation 2021. (31) (25)For NSW workplaces - A drug register is to be kept as per the NSW Health Authorisation to possess the substance that is obtained by the work unit. “Other Poisons” and “Highly dangerous Schedule 7 poisons”, as defined by this procedure, are also to be recorded in a register. The registers may be electronic or paper based and must include details (e.g. date, name, form, strength and amount of poison, nature of dealing) to be able to reconcile the amount of poison received, applied, supplied or disposed of. (32) The SMP will describe the procedures for: (33) Prevention of spillage, exposure or instability (34) The SMP must include a description of: (35) The SMP must: (36) Disposal of Substances must comply with SCU procedures for waste disposal as well as any specified by any substance licence conditions. (37) The SMP must describe procedures to ensure: (38) The SMP must describe procedures to prevent exposure of persons or environmental contamination above the relevant exposure standard for the Substance i.e. air monitoring or biological monitoring. (39) The SMP must: (40) The emergency plan must provide for: (41) Work Units wishing to obtain and possess Substances for the purpose of research, analysis or instruction must obtain the appropriate permissions from the relevant State Government (where applicable). (42) For centralised record keeping, the Responsible Person is required to forward the SMP and supporting documents to SCU’s Workplace Health and Safety team within 7 days of Head of Work Unit approval of a new and/or reviewed/updated document. (43) The SMP is required to be reviewed annually and updated as required. Evidence of the review and outcomes are to be approved by the Head of Work Unit. (44) Work Units wishing to work with S8/S9 Substances and Prohibited Drugs and Plants must submit an “Application for Authority to Possess or Supply Schedule 8 or Schedule 9 Substances, Prohibited Drugs/Plants for the Purpose of Research, Instruction, Analysis or Treatment of Animals” form to NSW Health. (45) The application form is available at NSW S8 S9 and Prohibited Plants Application Form. (46) A checklist to assist in making an application is available at the NSW Health website at Application checklist. (47) In NSW, Government authorisation to possess S2/3/4 Substances is not required as per this advice from NSW Health - “A scientifically qualified person who is in charge of a laboratory or department, or a person acting under the direct personal supervision of such a person, is authorised to possess and use any Schedule 2, 3 or 4 substance that is required for the conduct of medical or scientific research or instruction or the conduct of quality control analysis”. (48) For scheduled substances other than those listed above, refer to the NSW Health website at NSW Health Licences and Authorisations. (49) Work Units must submit an “Application for a General Approval – Research, Analysis & Teaching at a University” to QLD Health. (50) An application form is available at Application for a general approval - research, analysis and teaching at a university. (51) Additional information is available at Research and analytical laboratories using scheduled substances | Queensland Health. (52) The Responsible Person must ensure that Substances are appropriately used, handled, stored and correctly labelled in accordance with the Global Harmonized System of Classification and Labelling of Chemicals (GHS) or other applicable labelling requirements imposed. (53) Label requirements include, as a general minimum: (54) Each Work Unit must assess the requirement to provide health monitoring, in consultation with the Workplace Health and Safety Team, for workers who carry out ongoing work using, handling, generating or storing Substances and there is a significant risk to their health because of that exposure in accordance with the WHS legislation. The Safety Data Sheet for each Substance must also be reviewed to assess the requirement for health monitoring. (55) Information on health monitoring is provided in Division 6 Health Monitoring of the NSW WHS Regulation (2017) and QLD WHS Regulation (2011). Particular reference should be made to the substances listed in “Schedule 14 Requirements for health monitoring” of the NSW WHS Regulation (2017) and QLD WHS Regulation (2011) (56) If the results of health monitoring indicate that a worker is experiencing adverse health effects or signs of exposure to a Substance, the control measures and SMP must be reviewed and, if necessary, revised. (57) Health monitoring records must be retained by the Work Unit and a copy provided to HR Services to be stored in the employee’s personnel file. (58) Each Work Unit is to maintain and keep up to date a: (59) The SMP document and all activities relating to Substance management outlined in the policy and procedure are to be regularly audited and subject to review by a third party from outside the Work Unit. (60) The third party is to provide a report to the Work Unit on conformances/non-conformances found, along with any corrective actions or recommendations for improvement. (61) The Work Unit is to provide a response to the third party if corrective actions/non-conformances are found to demonstrate that appropriate remedial actions have been undertaken. (62) Refer to WHSMP13: Responsibility and Accountability Statement. (63) This Procedure will be reviewed as per nominated review dates or because of other events, such as: (64) Work Health and Safety Act (in the applicable jurisdiction that SCU operates) (65) Work Health and Safety Regulation (in the applicable jurisdiction that SCU operates) (66) WHS Regulation 2011 (QLD) - Health Monitoring (67) Work Health and Safety Act 2011 (NSW) (68) Work Health and Safety Regulation 2017 (NSW) (69) WHS Regulation 2017 (NSW) - Health MonitoringHRP06: Scheduled Substances
Section 1 - Purpose and Scope
Section 2 - Definitions
Substance Management Plan
Section 3 - General Requirements
Governance and operational arrangements
Responsible Person
Risk assessment
Storage and labelling
Dealings with Substances
Training and competency
Prevention of unauthorised purchase
Prevention of contamination
Prevention of fire
Suppliers
Drug and Poisons registers
Inventory of Stock
Prevention of diversion and theft
Disposal arrangements
Exposure or environmental contamination
Emergency plan and equipment
Authorisations from government bodies to possess scheduled substances
NSW Government Authorisation Requirements
QLD Government Authorisation Requirements
Labelling
Health Monitoring
Section 4 - Records of Documentation
Top of Page
Section 5 - Audit and Review
Section 6 - Roles and Responsibilities
Section 7 - Revision and Approval History
Top of PageSection 8 - References
Section 9 - Section 9 - Related Documents
QLD
NSW
Southern Cross University
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Substance Type.
Description.
Medicine.
A substance listed in the Poisons Standard (Commonwealth) in Schedules 2, 3, 4 and 8 that is intended for therapeutic use.
Prohibited substance.
A prohibited substance is a substance listed in Schedules 9 and 10 of the Poisons Standard.
Hazardous Chemical.
A substance, mixture or articles that satisfies the definition in WHS legislation.
Hazardous poison.
Is a S2, S3, S4 or an S8 poison or an S7 substance.
High-risk poisons.
Is an S8 poison or a prohibited substance.
Non-restricted S7 substances.
An S7 substance, other than a Restricted S7 poison.
Restricted Schedule 7 (RS7) poison.
Schedule 7 poisons in the Poisons Standard prescribed in Schedule 2 of the Poisons Regulation (QLD) requiring additional controls.
Highly dangerous Schedule 7 poisons.
Schedule 7 poisons as defined by NSW Health.
Other Poison.
Is a substance that has significant health risks, though not a scheduled substance and includes any or all of the following Hazard Statements on their Safety Data Sheets (SDS):
H300 Fatal if swallowed.
H310 Fatal in contact with skin.
H330 Fatal if inhaled.
SCU Transport, Storage and Disposal of Hazardous Substances Manual