• Section 1 - Introduction
• Section 2 - Scope 
• Section 3 - Definitions 
• Section 4 - General Requirements 
• Section 5 - Records  
• Section 6 - Audit and Review 

Section 1 - Introduction

(1) This procedure outlines the University's legislative responsibilities in respect of management of Scheduled Substances and Other Poisons (collectively, Substances). 

(2) Work units using Substances, for teaching, research or analysis or any other use must use and handle these Substances safely in accordance with NSW and QLD Acts, Regulations and SCU safety procedures.   

(3) If a Work Unit is to use a Substance(s) in Victoria, the work unit will need to consider applicable rules and regulations in Victoria by reviewing guidance materials available on Victoria’s safety regulator’s website (WorkSafe Victoria) and Part 4 of the Occupational Health and Safety Regulations 2017 (VIC).  

Section 2 - Scope 

(4) This procedure is applicable to the use of Substances, as defined in the Scheduled Substances, Hazardous Chemicals and Poisons Management Policy. 

(5) Where Work Unit operations fall across two or more jurisdictions, the higher threshold for management of Substances will apply. 

(6) This procedure is not applicable to the supply, prescription or administration of scheduled drugs by a practitioner in a clinical environment. 

Section 3 - Definitions 

Substance Management Plan 

(7) 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. 

(8) The SMP prepared by the Work Unit must contain the elements in this section to describe how Substances are managed and is to include: 

1. written procedures for all processes relating to Substances; 
2. assessments approved by the Head of Work Unit; 
3. listing and confirmation of meeting of applicable regulatory requirements;  
4. authorised staff; 
5. purchasing, receipt;  
6. storage;  
7. labelling; 
8. handling; 
9. end use;
10. disposal; 
11. training and competency; 
12. emergency plan and equipment; and 
13. keeping of registers and records. 

(9) Further guidance for preparing a SMP is available at QLD Gov Guidance SMP  

(10) A checklist to assist in preparing a SMP is available at SMP Checklist  

(11) 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. 

Section 4 - General Requirements 

(12) The SMP must: 

1. be easy to understand when, where, how and to whom it applies; 
2. be written in such a way that is easily understood by all relevant workers and students; 
3. be made available to all relevant workers and students at all times, including upon development and when materially revised; and 
4. be a controlled document, specifying the version history, date of review(s), the name(s) of the person who completed any review and the reason/s for the review(s). 

Governance and operational arrangements 

(13) The SMP must state the governance arrangements that ensure accountability for compliance with the SMP. Governance arrangements must include details relating to: 

1. roles and responsibilities; and 
2. delegations for the SMP. 

(14) The SMP must include the following operational details: 

1. the date of commencement of the SMP;  
2. who the SMP applies to (both workers and students); 
3. how workers and students will understand their roles and obligations under the SMP; 
4. how compliance with the SMP will be monitored, audited, reviewed and updated; and 
5. documents that form part of the SMP and their availability to workers and students (for example, the existing work health and safety management system or chemical management system). 

(15) 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: 

1. there is a substantial change to the internal or external operations related to the dealings, or in connection with, the place; 
2. a non-compliant audit outcome results in new risks being identified or recommendations to modify how known and foreseeable risks related to dealing with regulated poisons are managed; 
3. a systematic issue is identified; 
4. internal checks identify that an amount of a restricted S7 poison or high-risk poison possessed under the substance authority is not accounted for; 
5. release of a restricted S7 poison or high-risk poison possessed under a substance authority causes, or is likely to cause, someone to require medical treatment; and/or 
6. the holder of the substance authority is issued a compliance notice, or subject to administrative action or prosecuted for an offence under the Act (QLD). 

Responsible Person  

(16) 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. 

(17) 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.  

Risk assessment 

(18) 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.  

(19) The Head of the Work Unit must ensure the SMP and risk assessment is regularly reviewed and assessed.  

Storage and labelling 

1. The SMP must state the: 
2. location where the Substance is to be stored and/or used; and 
3. details of how the Substance will be stored at the location (e.g. locked cabinet/room and access controls) including: 
4. whether there are any applicable storage requirements in an applicable safety data sheet; 
5. being segregated from incompatible chemicals; 
6. separate from food, food packaging or personal use products, and 
7. away from ignition sources and combustible packaging materials.  

(20) The SMP must also state the process for ensuring all Substances are labelled and in closed containers.  

Dealings with Substances 

(21) The SMP must state: 

1. all dealings with Substances to which the plan applies; and 
2. details of compliance with the general requirements under the Poisons Regulation (QLD) in relation to record keeping, storage, transport and disposal of regulated poisons to which the plan applies. 

Training and competency 

1. 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. 
2. The SMP must state what the appropriate level of supervision is to be when using, handling or dealing with Substances.  
3. All workers and students who are expected or may come in contact 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.  

Prevention of unauthorised purchase 

1. The SMP must describe procedures for ensuring that only appropriately authorised persons buy Substances.  

Prevention of contamination 

(22) The SMP must include a description of how Substances will be stored to prevent contamination. Such descriptions should consider: 

1. segregation of Substances to prevent cross-contamination; and 
2. design and construction of storage areas to prevent contamination of products. 

Prevention of fire 

(23) 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.  

Suppliers 

(24) The SMP must list the suppliers of the Substances and record evidence that the Suppliers have appropriate authorisations to supply. 

Drug and Poisons registers 

(25) 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. 

(26) 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. 

(27) 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 are in Page 15 Subdivision 2 High-risk poison register of the QLD Medicines and Poisons (Poisons and Prohibited Substances) Regulation 2021 

(28) For NSW workplaces - A drug register is to be kept as per the NSW Health Authorisation to possess the substance which 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. 

Inventory of Stock 

(29) The SMP will describe the procedures for:  

1. conducting an inventory of Substances as well as it’s frequency;   
2. where discrepancies are found in the drug/poison’s registers; and 
3. additional inventory requirements of the Substances held as per their authorities and permissions from NSW and QLD Health. 

Prevention of spillage, exposure or instability 

(30) The SMP must include a description of: 

1. access controls to regulated Substances; 
2. measures to prevent the spread of contamination and clean-up of contamination;  
3. use of personal protective equipment (PPE) where necessary; 
4. spill containment;  
5. measures to prevent Substances from becoming unstable, decompose or changing; and 
6. first aid for exposed persons. 

Prevention of diversion and theft 

(31) The SMP must: 

1. include a description of security measures to prevent unauthorised access to Substances. Measures must consider the schedule of the Substance in the Poisons Standard; 
2. include a description of record-keeping methods to identify diversion or theft; 
3. include persons authorised under the plan to purchase Substances; and 
4. address internal distribution of Substances. 

Disposal arrangements 

(32) Disposal of Substances must comply with SCU procedures for waste disposal as well as any specified by any substance licence conditions. 

(33) The SMP must describe procedures to ensure: 

1. only authorised persons dispose of waste or witness disposal, giving consideration to the schedule of the Substance in the Poisons Standard, WHS legislation and the risk to public health; and
2. accurate record-keeping, including loss reporting. 

Exposure or environmental contamination 

1. 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.  

Emergency plan and equipment 

(34) The SMP must: 

1. provide for and outline an emergency plan that has been prepared in consultation with workers, emergency services and any relevant neighbouring premises, and  
2. outline the availability of fire protection, firefighting equipment, emergency equipment and safety equipment.  

(35) The emergency plan must provide for:  

1. emergency procedures including effective response to an emergency, evacuation procedures, notification to emergency services, medical treatment and assistance; 
2. testing procedures and how often they will be done; and 
3. how relevant workers and other persons (i.e. students) will be provided with information, training and instruction about implementing the emergency procedures.  
4. the SMP must also provide for the provision and availability of emergency and safety equipment.  

Authorisations from government bodies to possess scheduled substances 

(36) 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). 

(37) 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.   

(38) 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.  

NSW Government Authorisation Requirements 

(39) 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. 

(40) The application form is available at NSW S8 S9 and Prohibited Plants Application Form. 

(41) A checklist to assist in making an application is available at the NSW Health web site at Application checklist. 

(42) 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”. 

(43) For scheduled substances other than listed above refer to the NSW Health web site at NSW Health Licences and Authorisations. 

QLD Government Authorisation Requirements 

(44) Work Units must submit an “Application for a General Approval – Research, Analysis & Teaching at a University” to QLD Health. 

(45) An application form is available at Application for a general approval - research, analysis and teaching at a university . 

(46) Additional information is available at Research and analytical laboratories using scheduled substances | Queensland Health. 

Labelling  

(47) 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 requirement imposed.  

(48) Label requirements include, as a general minimum: 

1. the product identified; 
2. the name, Australian address and telephone number of the manufacturer or importer; 
3. the identity and proportion for each ingredient of the chemical; 
4. any hazard pictogram, signal word and precautionary statement consistent with the correct classification of the chemicals; 
5. any information about the hazards, first aid and emergency procedures relevant to the chemical; 
6. the chemical’s expiry date (if it has one); and 
7. any other requirements specific to the substance being used in accordance with its safety data sheet.  

Health Monitoring 

(49) 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.  

(50) 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) 

(51) 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. 

(52) 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. 

Section 5 - Records  

(53) Each Work Unit is to maintain and keep up to date a: 

1. Substance register which includes: A list of all Substances used, handled or stored at the relevant SCU workplace; and 
2. Current (not more than 5 years old) safety data sheets for each Substance listed (where available).   
3. SMP training records of workers and any other persons (including students).  
4. Each Work Unit is to obtain a current safety data sheet from the manufacturer, importer or supplier of the Substance before it is used.  
5. Where applicable, each Work Unit must maintain a manifest of the hazardous chemicals used and stored on site meet the quantities required under the WHS legislation.  
6. The University is to maintain records of health monitoring reports for at least 30 years after the record is made or 40 years if the report relates to asbestos exposure. All health monitoring records are to be kept confidential and maintained in accordance with the Australian Privacy Principles.  
7. Substance registers, safety data sheets, manifest and SMPs must be readily accessible to workers and students involved in using, handling or storing Substances, and anyone else who is likely to be affected by it.  

Section 6 - Audit and Review 

(54) The SMP document and all activities relating to Substances 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. 

(55) 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. 

(56) 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.