Current through all regulations passed and filed through September 16, 2024
(A)
Policy
statement
The university of Toledo shall have a
fire and life safety plan.
(B)
Purpose of
policy
To help protect the lives of students,
patients, staff, faculty, visitors, and its buildings from fire hazards. The
fire safety plan will meet the mandates of local, state and national building
and fire codes. The plan requires the provision of protocols and procedures for
ensuring the creation, maintenance and improvement of fire safety systems for
all campus buildings and locations. To ensure that all structures are fire safe
and equipped with all of the proper operational equipment necessary to handle
fire safety/fire prevention issues effectively and expeditiously; to ensure
that all individuals entering campus grounds and locations are protected and
well-educated on the major tenets of fire safety/fire prevention and
response.
(C)
Design and responsibility
The following departments are
responsible for preservation of life and fire safety at the university of
Toledo.
(1)
The environmental health and radiation safety
department, university police, risk management and maintenance/plant operations
are responsible for the overall provision of the fire safety plan at the
university of Toledo.
(2)
Environmental health and radiation safety assisted by
various university departments is tasked with the development of procedures,
programs and plans to serve as procedural guidelines for institutional and
academic departments in regards to life and fire safety.
(3)
Maintenance/plant operations is responsible for the selection, installation,
maintenance and inspection of all fire safety devices designed to detect and
prevent fires in and around campus buildings.
(4)
Additional,
safety and health programs, plans and procedural guidelines can be found
at
www.utoledo.edu/depts/safety.
(D)
The university
develops and maintains a written management plan describing the processes it
implements to effectively manage fire and life safety. The plan will:
(1)
Identify and
implement proactive processes for protecting patients, staff, and others coming
to the facilities, as well as protecting property from fire, smoke, and other
products of combustion: This is achieved primarily by the patient care
buildings being built in compliance with established codes of the local and
state fire marshal authorities and Ohio building code provisions, and in
accordance with guidelines delineated by the American institute of architects
"AIA." Facilities maintenance, campus police and environmental health and
radiation safety staff provide protection to all occupants by conducting life
safety rounds, security patrols and fire drills that test staff knowledge of
and response to fire situations.
(2)
Identify and
implement processes for regularly inspecting, testing and maintaining fire
protection and fire safety systems, equipment and components: This is achieved
through an established preventive maintenance "PM" program which is tracked and
monitored for compliance by the facilities maintenance department. A
computerized matrix for testing of the various fire alarm and fire
notification/detection/prevention systems and the intervals for such testing
are maintained by facilities maintenance in accordance with both local and
state requirements, and applicable joint commission standards for
testing.
(3)
Develops and implements a fire response plan that
addresses the following:
(a)
Facility wide fire response;
(b)
Area-specific
needs including fire evacuation routes;
(c)
Specific roles
and responsibilities of staff, faculty, students, visitors and volunteers at a
fire's point of origin;
(d)
Specific roles and responsibilities of staff, faculty,
students, visitors and volunteers away from a fire's point of
origin;
(e)
Specific roles and responsibilities of staff, faculty,
students, visitors and volunteers in preparing for building
evacuation.
(4)
The five requirements mentioned above are addressed in
procedure LS-08-001 (code red---campus fire response
procedure).
(5)
Review proposed acquisitions of bedding, window
draperies, and other curtains, furnishings, decorations, and other equipment
for fire safety: The purchasing department works with vendors who verify,
through written affidavits or certifications, the fire safety features of the
acquisitions listed above. Purchases of bedding, curtains and furnishings are
usually done through national companies whose products comply with mandates
regarding fire prevention/life safety safeguards; in addition, the university
follows the guidelines spelled out in California technical bulletin 133 and
national fire protection association "NFPA" 701.
(6)
Reporting and
investigating fire protection deficiencies, failures and user errors: errors
and deficiencies of this nature are reported to the facilities maintenance work
control center if a structural component of existing life safety protection is
compromised, or to the appropriate university contractor liaison if the
deficiency is related to construction and renovation/remodeling being done by
outside contractors. In addition, after fire drills are completed, the drill
conductor consults with supervisory staff in the department(s) drilled, and
identifies any deficiencies, failures, user errors or staff knowledge gaps to
those supervisors, so the issues identified can be immediately addressed and
corrected.
(7)
A life safety orientation and education program that
addresses fire safety issues: The fire prevention plan encompasses provisions
for the education of staff, faculty, students, visitors, volunteers and others
on fire safety/fire prevention protocols. The university has implemented the
r=rescue, a=alarm, c=confine, e=extinguish "R.A.C.E." acronym in training
persons on the hazards of fire. In addition, the level of staff, faculty, and
students, visitors and volunteer's knowledge of fire safety is assessed by
random queries made during monthly environmental safety rounds, and by
reinforcement through the employee safety training.
(8)
The management
plan describes all of the processes required for fire safety planning,
including:
(a)
Process description
(i)
The university protects patients, staff, faculty,
visitors, volunteers and property from the dangers of fire, smoke and
combustion primarily by ensuring that all buildings are constructed in
compliance with the life safety code and with guidelines and recommendations
issued by the American institute of architects "AIA." The ban on smoking inside
buildings on the campus contributes a great deal to ensuring a fire-safe
environment.
(ii)
The structural safeguards in place in buildings of the
university, such as smoke detectors, pull station alarms, heat detectors,
damper alarms, sprinkler systems and fire extinguishers all contribute greatly
to the fire safety/fire prevention at the university.
(iii)
An important
component of the life safety program at the university is the strong
partnership that exists between the university and the local and state fire
marshals' bureaus. The local fire marshal conducts an intensive wall-to-wall
survey of all campus buildings regularly.
(iv)
The fire marshal
makes detailed recommendations for change or correction. These recommendations
are reported to the facilities maintenance department for action and
follow-up.
(b)
Establishing, supporting and maintaining fire
safety
(ii)
The
university fire prevention plan has been established to provide guidelines to
the safety and health committee and the appropriate maintenance/construction
support activities so that the university meets the guidelines set forth in
NFPA life safety code 101 as they relate to its existing
occupancies.
(ii)
Included in this process are life safety assessments
"LSA" which outline a course of action to improve overall fire
safety.
(c)
Fire safety education
Education is a key component of the
fire safety plan and is intended to provide an understanding of the
university's fire prevention plan.
(d)
Compliance with
interim life safety measures during periods of construction
The university institutes interim life
safety measures during periods of construction when certain features of life
safety protections will be curtailed or interrupted.
(e)
Inspecting,
testing and maintaining the fire alarm systems
The university provides clear processes
for the inspection, testing and maintaining of its fire alarm system by
conducting testing as required on the fire alarm circuits by in-house
facilities maintenance staff. The logs and reports of testing, and
documentation of this testing are maintained in the facilities maintenance
department.
(f)
Inspecting, testing and maintaining all automatic fire
extinguishment systems
The university maintains clear
processes for the inspection, testing and maintaining of its automatic fire
extinguishing systems in accordance with state of Ohio, city of Toledo and "JC"
stipulations.
Reports of that testing and records of
contracted services for that work are kept in the facilities maintenance
department.
(g)
Managing portable fire extinguishers
(h)
Health science
campus: The university's environmental health and radiation safety department
has the responsibility to identify, place, inspect and maintain on a regular
basis the portable fire extinguishers on the campus. The annual servicing and
recharging (if necessary) of fire extinguishers is performed by a certified
outside contractor, familiar with the requirements of fire extinguisher
maintenance protocols. The records of monthly fire extinguisher checks are kept
in the environmental health and radiation safety department.
(i)
Main campus: The
university's facilities and construction has the responsibility to identify,
place, inspect and maintain on a regular basis the portable fire extinguishers
on the campus. The annual servicing and recharging (if necessary) of fire
extinguishers is performed in house, familiar with the requirements of fire
extinguisher maintenance protocols. The records of monthly fire extinguisher
checks are kept in facilities and construction.
(j)
Reporting and
investigating life safety code and fire protection deficiencies, failures and
user errors
The university staff has the
responsibility for ensuring the institution's compliance with life safety code
or fire prevention provisions. They are asked to report any suspected
deficiency in life safety code processes. This is accomplished through the
initiation of work orders submitted to the facilities maintenance department,
or by immediately notifying the environmental health and radiation safety
department to report a life safety code violation or concern. Facilities
maintenance and university police staff submits work orders or occurrence
reports as applicable to initiate repair of or to draw attention to suspected
or actual life safety code violations/problems.
(k)
Overriding
authority
The director of environmental health
and radiation safety has the authority to mandate the immediate correction or
alleviation of any life safety code violations he/she deems serious enough to
warrant such immediate action. Her/his authority for such action is fully
supported by the university's administration.
(l)
Performance
monitors
Performance monitors accurately assess
the effectiveness of key aspects of the fire safety/fire prevention plan. These
monitors are tracked and trended in order to develop a historical view of the
rate of effectiveness.
|
Approved by: |
Policies Superseded by This Policy:
* Previous 3364-60-03, effective date July 28,
2008, Previous 3364-60-03, effective date May 28, 2014
Initial Effective Date: July 28, 2008
Review/Revision Date: September 23, 2011; September 1, 2012; March
31, 2014; July 28, 2017
Next Review Date: July 28,
2020 |
|
Sharon L. Gaber, Ph.D.
President July 28,
2017
Date
Review/Revision Completed by:
Director of Environmental Health and Radiation
Safety
|
