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Faculty Guide to Compliance Requirements |
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This guide was developed as a tool to provide convenient and concise information regarding the various compliance activities faculty members at Washington University are required to fulfill. To use this guide, simply find the activity you are engaged in and then the applicable requirements will be listed in the Requirement column, with subsequent information provided on how to complete the requirement, hyperlinks that go directly to the requirement, and the estimate time it will take fulfill the requirement. The hyperlinks located in the For More Information column will take you to appropriate websites for additional information. If you have questions regarding a specific requirement, please contact the applicable office.
While every effort has been made to develop a comprehensive list, this may not represent the entire list of requirements faculty are required to fulfill.
A PDF version of this Guide is available for downloading: Faculty Guide to Compliance Requirements (PDF) |
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Core Requirements: |
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Activity |
Requirement |
Reason for Requirement |
Necessary Steps to Fulfill Requirement |
Estimated Time Requirement |
To Fulfill the Requirement |
For More Information |
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All Faculty |
Basic EHS Training
Required for all faculty hired after March 10, 2008 |
Faculty are required to have basic safety training. |
· Enter your employee ID number and AIS/HRMS password · Click Go To Breeze Training then follow the instructions provided |
.25 Hours One-time only |
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Environmental Health and Safety 935-9264 |
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Code of Conduct |
The Code of Conduct underscores the University's commitment to integrity, ethical conduct, and legal compliance in everything we do. |
· Enter your employee ID number and AIS/HRMS password · Click on Code of Conduct on the left side of the screen · Follow the instructions provided. · Read Materials · Certify Commitment |
.5 Hour Annually |
University Compliance Office 362-4910 |
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Financial Disclosure Statement (COI) |
Washington University policies and Federal Regulations require financial disclosures on a regular basis or as changes occur in financial interests or research/patient care activities. |
· Enter your employee ID number and AIS/HRMS password · Click on Financial Disclosure Statement on the left side of the screen · Then follow the instructions provided |
.25 – 1 Hour Annually |
Research Ethics and Compliance Office 747-2904 |
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All School of Medicine Faculty & Danforth Faculty involved in Research |
Effort Reporting Education |
All Faculty are required to complete Effort Reporting Education as a commitment to the stewardship of federal funds and the appropriate proposing and reporting of effort |
· Enter your employee ID number and AIS/HRMS password · Click Go To Breeze Training then follow the instructions provided · Watch Presentation · Take Quiz |
.5 Hour One-time only |
Research Ethics and Compliance Office 747-5571 |
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All School of Medicine (WUSM) Faculty with an appointment in a clinical division. |
Expert Witness Attestation |
WUSM has established a Code of Conduct, as well as this Policy for Expert Witness Testimony, for faculty members who serve as expert witnesses. |
· Read the Expert Witness Code of Conduct. · Print and sign the Expert Witness Affirmation · Mail form to the Office of Risk Management |
.25 Hour One-time only
However, submission of expert witness testimony activity is required annually
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Risk Management 362-6956 |
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Requirements Based on a Specific Activity: |
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Activity |
Requirement |
Reason for Requirement |
· Necessary Steps to Fulfill Requirement |
Estimated Time Requirement |
To Fulfill the Requirement |
For More Information |
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Research involving Animals |
Animal Studies Education |
Animal Welfare regulations and the Public Health Service Policy require institutions to ensure that people caring for or using animals are qualified to do so. |
· Click on link provided to the right · Read Introductory Slides · Click on link to training modules |
.5 – 1.5 hours One Time Only and Annual depending on modules |
Department of Comparative Medicine 362-3700 |
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ASC Protocol |
The ASC is required by federal regulations to review all projects (research, teaching, or other) involving the use of vertebrate animals. This is required if funding is through Washington University, or if the animal is housed at this institution. |
· Complete eSirius account request form · Fax completed and signed form to ASC · eSirius account will be set up upon receipt and your log-in and password sent to you |
1 – 1.5 Hours |
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Animal Studies Committee office 362-3229. |
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Participating in CME activities sponsored by WUSM |
CME Disclosure of Financial Relationships |
All speakers, planning committee members, or persons in a position to influence the content of an educational activity, are expected to disclose to the audience any financial interest or other relationship |
· Enter your employee ID number and e-mail · Then follow the instructions provided |
.25 - .5 Hour |
Continuing Medical Education Office 362-6891 |
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Working with a gamma irradiator |
Irradiator Exam and training |
An individual needing to use a self-shielded gamma irradiator at Washington University and the Medical Center should contact Radiation Safety for information on the process, security requirements, and alternatives. |
· Formal request by individual’s Authorized User or Department · Successfully pass a background check including fingerprinting & FBI criminal history records check · Irradiator Exam · Facility Training · Operator Training · IC Program Didactic Security Training · IC Program Hands-on Security Training · Annual Refresher Training is also required. |
Initially: 2 to 6 months for background check
6 to 8 Hours spread over 4 to 6 weeks for exam & training
Annually: 1 Hour |
Phone (362-3476) or email radsafety@wustl.edu |
Radiation Safety 362-3476 |
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Research involving human subjects |
HRPO Protocol Submission |
Studies which need IRB approval should be submitted to the Human Research Protection Office. |
· Download appropriate form from HRPO’s Website · Complete the form and submit it to the HRPO Office · Complete Human Subjects Training |
.5 – 2 Hours |
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Human Research Protection Office 633-7400 |
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Human Subjects Research Training Module (CITI) |
School of Medicine researchers will need to complete the Biomedical Investigation track. - or- Danforth Campus Researchers will need to complete either: -Researchers in Social Work, Anthropology, Economics, Education, Political Science, Psychology, Program in Philosophy, Neuroscience & Psychology, Program in Social Thought and Analysis or -All other Danforth Depts./Schools |
· Click on the link provided to the right · Enter your employee ID number and AIS/HRMS password · Click on Human Subjects Education on the left side of the screen · Follow the instructions provided |
2 - 4 Hours One-Time Only |
Human Research Protection Office 633-7400 |
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Working in a laboratory setting |
EH&S Annual Lab Safety Training |
WU laboratory and clinical faculty, staff, and students working in laboratories are required to have annual training covering OSHA and EPA topics. |
· Click on the link provided on the right and choose which option best suites your situation · If choosing On-Line Training, enter your employee ID number and AIS/HRMS password · Click Breeze Training on the left side of the screen, then follow the instructions provided |
2 Hours Annually |
Environmental Health and Safety 935-9264 |
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Working with lasers |
Confirm that Radiation Safety has the machine on its inventory list |
To notify Radiation Safety of the presence of the machine, to ensure it is placed on the inspection schedule, and confirm that the PI has safety program implemented. |
· Complete inventory form and submit to Radiation Safety · Annual safety audit |
Initially: 0.5 Hour
Annually: 1 Hour audit |
Submit laser inventory form to Radiation Safety by fax at 362-4776, email attachment to radsafety@wustl.edu, or Campus Mail box 8053. |
Radiation Safety 362-3476 |
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Working with strong magnetic fields |
Confirm that Radiation Safety has the machine on its inventory list |
To notify Radiation Safety of the presence of the machine, ensure it is placed on the inspection schedule, and confirm that the PI has safety program implemented. |
· Submit inventory form. · Annual safety audit
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Initially: 0.5 Hour
Annually: 1 Hour audit |
Submit inventory form to Radiation Safety by fax at 362-4776, email attachment to radsafety@wustl.edu, or Campus Mail box 8053.
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Radiation Safety 362-3476 |
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Provide patient care or clinical lab services |
Office of Physician Billing Compliance – Billing Compliance 101 |
Employees (faculty physicians, fellows, and staff) must participate annually in billing compliance education if they are involved in patient care services, and/or if they are involved directly or indirectly in the professional reimbursement process. |
· Click on the link provided on the right, · Enter your employee ID number and AIS/HRMS password · Click Breeze Training on the left side of the screen, then follow the instructions provided |
1 Hour Annually |
Office of Physician Billing Compliance 747-7661 |
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EH&S Annual Clinical Safety Training |
WU laboratory and clinical faculty, staff, and students working in laboratories are required to have annual documented training covering OSHA and EPA topics. |
· Click on the link provided on the right and choose which option best suites your situation · If choosing On-Line Training, enter your employee ID number and AIS/HRMS password · Click Breeze Training on the left side of the screen, then follow the instructions provided |
2 Hours Annually |
Environmental Health and Safety 935-9264 |
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Risk Management Patient Safety Training |
The MedRisk training program provides risk prevent skills training specific to a physician’s specialty or area of interest |
· Follow link to the MedRisk welcome page. · Register by using your Employee ID as your username and establish a password of your choice. · Choose course and follow directions provided. |
2-4.5 Hours One-Time Only |
Risk Management Elaine Cooper 362-4645 |
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Working with positron emitting radioactive materials (PET isotopes) |
PET Safety Exam and training to qualify as PET Worker |
Ensure training and regulatory compliance for personnel working in positron emission tomography (PET) facilities, cyclotron facilities, or PET radiochemistry laboratories. |
· Qualify as Radiation Worker, below. · For initial training, download the training manual. · Call or email Radiation Safety to schedule an appointment to take the PET Safety Exam (362-3476 or radsafety@wustl.edu) · Annual Refresher Training is also required. |
2 Hour initially
1 Hour annually |
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Radiation Safety 362-3476 |
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Access to Protected Health Information (PHI) |
HIPAA Training |
HIPAA training is required for everyone who accesses PHI.
*Annual refresher training, while not mandated by the University, is mandatory for some departments. Please contact your Department Administrator for further information. |
· The HIPAA Privacy Liaison for your department will e-mail you with a log-in, password, and instructions for the HIPAA training system. |
1 -1.5 Hours One-Time Only* |
Privacy Office 747-4975 |
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Working with radioactive materials |
Radiation Safety Exam and training to qualify as Radiation Worker |
Ensure training and regulatory compliance for personnel prior to working with radioactive materials |
· For initial training, download the training manual. · Call or email Radiation Safety to schedule an appointment to take the Radiation Safety Exam (362-3476 or radsafety@wustl.edu) · Annual Refresher Training is also required. |
2 Hour initially
1 Hour annually |
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Radiation Safety 362-3476 |
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Faculty Principal Investigator needing to use radioactive materials (may include PET) in non-human research |
Approval to possess and use radioactive materials as Authorized User, for non-human research. |
Ensure training and experience and regulatory compliance for Radiation Safety Committee approval of Authorized Users. |
· Qualify as Radiation Worker or PET Worker as appropriate, above · Document more than 40 hours of training and relevant hands-on experience with radioactive materials (T&E Form). · Submit an Application. · Participate in an Authorized User interview. |
Initially: 1 Hour for form and application
2 to 4 weeks for review and approval
Approval lasts 2 to 5 years |
Submit a T&E Form and an Application to Radiation Safety by fax at 362-4776, email attachment to radsafety@wustl.edu, or Campus Mail box 8053. |
Radiation Safety 362-3476 |
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Research that employs: recombinant DNA, biological toxins, infectious microorganisms, potentially infectious cell lines, animal or human tissues or fluids |
IBC Protocol |
This form provides OBCS and the Institutional Biological and Chemical Safety Committee a detailed description of regulated or hazardous research elements and their management, providing a basis for risk assessment. |
· Download appropriate form from the link to the right · Complete the form and submit it to the Office of Biological and Chemical Safety, Environmental Health and Safety Office |
2 - 4 Hours
IBC approval is valid for 5 years. |
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