+----------------------------+------------+---------------------------+
| **BROOKHAVEN NATIONAL      | ####       | REV.                      |
| LABORATORY**               | ### NUMBER |                           |
|                            |            | 0                         |
| D                          | LS-SAP-08  |                           |
| epartment/Division/Project |            |                           |
+----------------------------+------------+---------------------------+
| ##                         | 10/19/07   | PREPARED BY:              |
|  Life Sciences Directorate |            |                           |
|                            |            | ###### Emrick             |
|                            |            |                           |
|                            |            | Reviewed by: W. Gunther,  |
|                            |            | J. Bullis, S. Ferrone, R. |
|                            |            | Colichio, L. Mausner, J.  |
|                            |            | Desmond, C. Burns         |
+----------------------------+------------+---------------------------+
| SUBJECT:                   | APPROVED   |                           |
|                            | BY:        |                           |
| #####                      | (signature |                           |
|                            | on file    |                           |
| #####                      | with       |                           |
|  FY08 Self Assessment Plan | Self-      |                           |
|                            | Assessment |                           |
|                            | Mgr)       |                           |
|                            |            |                           |
|                            | Carl       |                           |
|                            | Anderson:  |                           |
|                            |            |                           |
|                            | Gene-Jack  |                           |
|                            | Wang:      |                           |
|                            |            |                           |
|                            | Fritz      |                           |
|                            | Henn:      |                           |
+----------------------------+------------+---------------------------+

1.  **Introduction and Purpose**

This self-assessment plan for FY 2008 is a derivative document based on
guidance given in the Laboratory\'s Integrated Assessment Subject Area
(IAP), the Critical Outcome document, and the goals listed in the
Biology and Medical Departments Mission Statements.

Generally, an integrated assessment program is designed to generate
information that can be used to make fact-based decisions on improving
the programmatic, operational and business performance within the
Laboratory. The Integrated Assessment Program is structured to:

-   provide accurate operational (including environment, safety, and
    health), technical, and business performance information to promote
    early identification and resolution of problems that may impact
    achievement of the Laboratory\'s Critical Outcomes and Directorate
    or Department objectives;

-   contribute to ongoing performance improvement, including driving the
    Laboratory improvement agenda through the identification of
    strategic and tactical investments and changes to the Critical
    Outcomes;

-   verify stakeholder and customer expectations and requirements to
    improve science and technology research, existing products and
    services and enhance customer satisfaction;

-   validate conformance to established internal and external
    requirements.

The key processes of this Self Assessment Plan used by the Life Sciences
Managers to obtain, evaluate, and use information for decision making
include:

-   Directorate operational planning based on Laboratory\'s strategic
    goals and critical outcomes,

-   monitoring performance against these and other
    (Directorate-specific) plans, objectives and performance measures,

-   evaluating overall performance and identifying areas for
    improvement, and

-   implementing actions for improvements.

> This document describes the assessment activities, assessment methods,
> and schedules the Life Sciences Directorate will use to
> monitor/measure the progress being made toward achieving those
> objectives and in providing assurances that Directorate-specific
> critical systems/processes that have a direct effect on performance
> are being adequately managed internally. It also includes the
> Directorates environmental and OSH objectives and the respective
> action plans necessary to achieve these objectives. These additions
>
> reflect one of the Directorates improvement initiatives to streamline
> the EMS and OSH Programs since obtaining ISO 14001 and OHSAS 18001
> registrations. Execution of this self-assessment plan provides the
> Directorate one of several mechanisms for ensuring that Directorate
> standards and procedures are consistent with applicable requirements
> and provisions of the Lab-level ESH&Q program.
>
> Although the overall assessment planning and the evaluation criteria
> that Life Sciences has utilized are based on a framework built around
> the Malcolm Baldrige Award Criteria, this document and the activities
> described herein are still evolving. Future assessment planning and
> concomitant activities will be based on previous assessment
> results/evaluations, changes in the Directorate objectives, BNL
> environmental and OSH priorities, evolving Laboratory Management
> System Initiatives, and current forecasts about the business climate.

1.  **Biology and Medical Department Mission Statements**

    1.  **Biology Department**

> The mission of the Biology Department is to produce excellent science
> and advanced technology in a safe, environmentally benign manner, and
> to develop complex facilities that take advantage of the Laboratory's
> unique resources and support the needs of the wider research community
> in areas such as structural biology and radiation biology. Essential
> for this mission is maintenance of a vital and stimulating research
> environment that will attract and nurture the best scientists and
> engineers for research and development programs in support of DOE
> missions and broader national goals. Interacting programs of basic and
> applied research in molecular and cell biology, biochemistry,
> structural biology, and genomics provide such an environment, in which
> the development and improvement of complex user facilities can
> flourish. An integral part of our mission is to transfer knowledge and
> technologies generated in the Department to others, through
> publications, presentations, collaborations, workshops, educational
> programs, the training of pre-doctoral and postdoctoral students, and
> patenting and licensing to the commercial sector.

2.  **Medical Department**

> The Medical Department\'s mission is to take advantage of the unique
> facilities and expertise at Brookhaven National Laboratory (BNL) for
> their potential application in medical research. In that process it
> uses nuclear technology and radiopharmaceuticals to develop new
> treatments, new diagnostic tools, and to study human physiology and
> the mechanisms of disease in the areas of oncology and neuroscience.
>
> The major, long term research goals of the Department include:

######## Radiation Treatment

> Investigate new forms of radiation treatment.

######## Imaging

> \(A\) Characterize the molecular changes underlying drug addiction and
> alcoholism and their relationship to function and treatment, and
> assess the neurobiological characteristics associated with
> predisposition for drug addiction.
>
> \(B\) Investigate molecular changes underlying normal aging and their
> relationship to vulnerability to neurodegenerative disease and
> treatment.
>
> \(C\) Investigate the actions of therapeutic drugs in the human body
> to optimize their beneficial effects, minimize toxicity and expedite
> their introduction into the practice of health care.

######## Radioisotopes

> \(A\) Supply isotopes for science and medicine.
>
> \(B\) Development and evaluate radiopharmaceuticals for cancer
> diagnosis and treatment.

######## Instrumentation

> \(A\) Use the National Synchrotron Light Source (NSLS) to develop new
> radiation treatments based on the delivery of very narrow beams of
> high doses of irradiation for the treatment of malignant brain tumors.
> These narrow beams allow delivery of significantly higher doses of
> radiation to the brain without the problems of irradiation necrosis
> encountered with conventional treatments.
>
> \(B\) Use NSLS for computed tomography (CT) scanning, mammography and
> bronchography. The high flux enables delivery of monochromatic rays
> that provide considerable improvement on the contrast gradient for
> structures with different densities than those obtained with
> conventional X-ray machines.

######## Radiobiology

> \(A\) Investigate the cellular mechanisms involved with radiation
> induced cell damage.
>
> \(B\) Investigate the effects of heavy particle radiation that mimics
> radiation effects of space on cells and whole organisms.
>
> The success of our research program is dependent upon the propitious
> use of the unique facilities and resources at BNL. Although much of
> the work is clinical, with direct application to human health
> problems, the Department also maintains basic research capabilities
> that provide an infrastructure for the clinical studies. To this end,
> collaborations with other BNL departments, particularly Biology,
> Chemistry, NSLS and the Collider-Accelerator as well as with non-BNL
> institutions are critical. The research is dependent on the
> collaboration from various clinical institutions including the State
> University of New York at Stony Brook, Columbia University, New York
> University, and Beth Israel Medical Center.

**3.0 Roles and Responsibilities**

**ALD, Life Sciences** - The ALD, Life Sciences is responsible for the
management and oversight of the Life Sciences self-assessment program.

**Department Chair-** The Biology and Medical Department Chairs are
responsible for the development and implementation of a self-assessment
program (as defined in the IAP Subject Area). The Chairs are also
responsible and accountable for ensuring that appropriate corrective
action to identified weaknesses is taken, commensurate with hazard,
risk, vulnerability, and overall research objectives.

**Line Managers**- Line Managers are responsible for conducting an
assessment of research activities, facilities, and operations under
their purview.

**Staff**- staff (including guests and subcontractors) are responsible
for assessing and improving their work and work processes.

**Self-Assessment Manager (SAM**)- is responsible for drafting the
self-assessment program with members of the Department and submitting it
to the Department Chairs and then the ALD, Life Sciences for final
approval. The SAM will gather status and data information from those
responsible for self-assessment activities. The SAM will analyze this
data against the Directorate's goals and objectives and track the
implementation of appropriate corrective actions based upon the
analysis. The SAM will provide a year-end summary to the Department
Chairs and the ALD for Life Sciences (i.e Operations Management Review
Meeting, S&T reporting).

4.  **Self-Assessment Overview**

The Life Sciences (LS) Directorate Self-Assessment Plan (SAP) is broadly
based on the Laboratory\'s Performance Evaluation and Measurement Plan.
The LS Directorate assesses the elements that are relevant to its
internal strategic plans, operations, and objectives, with the goal of
enhancing the performance of the LS Directorate and contributing to the
Critical Outcomes of the Laboratory. As the primary mission of the
Directorate is to facilitate the basic research and development
activities of its scientific staff and the excellence of its scientific
facilities, the SAP emphasizes those areas critical to enhancing this
mission. Furthermore, the SAP is designed so that the self-assessment
process deals with issues over which Directorate policy and operations
can influence future performance and avoids measures that focus on
narrowly defined quantitative aspects of research or operations.
Essentially, the process entails i) the collection of data on the
Directorate\'s performance measures; ii) the analysis of these data
against the Directorate's objectives; and, iii) the implementation of
appropriate corrective actions based upon the analysis.

4.  **Implementation**

The Directorate has always undergone self-assessment through its various
internal committees that address specific areas (ES&H, Support Staff
Review, Continuing Appointments Review, etc) as well as external
committees (advisory, visiting, DOE Review, etc). The SAP outlined here
formalizes the process and uses the Laboratory\'s Critical Outcomes to
obtain a broader view of the Directorate\'s performance. Input for the
contents of the SAP include the Biology and Medical Department Chairmen,
the SAM and other members of the staff (scientific, technical,
administrative-safety, administrative-business). The SAP incorporates
the following elements:

-   **Assessment Criteria:** These number codes refer to the Baldrige
    Award Criteria which best match the specific area of
    self-assessment.

-   **Objective:** A subset of the Laboratory\'s Critical Outcomes, or
    the self-assessment activities required of other Laboratory
    initiatives and programs as they relate to the LS Directorate.

-   **Approach (ISO 14001/18001 Targets):** Within our objectives we
    have defined an approach with which to accomplish the assessment
    activity. The approach is an action or series of actions taken to
    provide confidence that the Objectives and Performance Measures can
    be achieved examples include; the establishment of formal project
    controls, special funding, communications, assignment of specific
    tasks or responsibilities, etc.

-   **Measures:** Specific performance expectation selected to monitor
    and measure achievement of an Objective. They are quantified where
    practical.

-   **Schedule/Due Date:** Frequency of evaluation and date to be
    conducted.

-   **Maintenance or Improvement:** This data provides detail as to
    whether the activity is solely a maintenance activity or an
    improvement initiative.

-   **Responsibility**: The person, position or group responsible for
    specific self-assessment measures. They will conduct the appropriate
    tasks and report the status of those tasks to the SAM. They will
    work with the SAM to analyze the data collected for inclusion in a
    year-end Directorate summary. The responsible person is also
    responsible for tracking and assuring the implementation of any
    corrective, preventative or improvement actions.

The SAP matrix (Attachment 1) will be used to drive the self-assessment
process and set responsibilities, with individuals or committees to
evaluate performance or collect information. A summary of ESH
improvement initiatives is included in Attachment 2. The responsible
persons/positions will report status to the Self-Assessment Manager. The
Biology and Medical Chairs and/or ALD, Life Sciences are responsible for
making all assignments. The year-end summary (ie Management Review) will
be prepared by the SAM and presented to management and will be used to
set objectives for the next self-assessment cycle. In addition to the
plan outlined in the SAP matrix, ad hoc assessments may be set up on an
as-needed basis. The results of any ad hoc assessments and DOE-BHSO
assessments will be included in the year-end summary(s).

Routine review and updates of organizational documents is recognized as
an important aspect of Life Sciences operations. Specific documents are
often referenced as part of the LS "Approach (ISO 14001/OHSAS 18001
Targets)" for achieving performance objectives. Examples include, R2A2s,
Experimental review documents, environmental aspects analysis, process
evaluations etc. LS tracks this type of routine activity in the Family
ATS system or other tracking system. Therefore they are, as a practice,
not always identified as specific measures.

Life Sciences S&T Performance measures are included in and tracked
through the Office of Policy and Strategic Planning.

Existing operating budgets will be used to carry out the tasks
identified in the Self Assessment activities unless otherwise specified.

> **6.0 Corrective, Preventative, and Improvement Action Management**

The Directorate follows the corrective action management in the [Events
and Issues Management Subject
Area.](https://sbms.bnl.gov/sbmsearch/subjarea/186/186_sa.cfm?parentID=186?parentID=186)

**7.0 Prioritization**

Priority is considered when establishing due dates for action. Those
actions that are required assessments and those for which LS has a
primary role are specifically identified.

## Attachment 1

## FY08 Self Assessment Activities

+----------------------+--------+-------------------------+---+-----------+
| *ASSESSMENT CRITERIA |        |                         |   |           |
| 5.0* Business and    |        |                         |   |           |
| Operational Results  |        |                         |   |           |
+----------------------+--------+-------------------------+---+-----------+
| *OBJECTIVE:*         |        |                         | P |           |
| Maintain and improve |        |                         | E |           |
| the quality of       |        |                         | M |           |
| research conducted.  |        |                         | P |           |
|                      |        |                         | 1 |           |
|                      |        |                         | . |           |
|                      |        |                         | 0 |           |
|                      |        |                         | P |           |
|                      |        |                         | r |           |
|                      |        |                         | o |           |
|                      |        |                         | v |           |
|                      |        |                         | i |           |
|                      |        |                         | d |           |
|                      |        |                         | e |           |
|                      |        |                         | f |           |
|                      |        |                         | o |           |
|                      |        |                         | r |           |
|                      |        |                         | E |           |
|                      |        |                         | f |           |
|                      |        |                         | f |           |
|                      |        |                         | i |           |
|                      |        |                         | c |           |
|                      |        |                         | i |           |
|                      |        |                         | e |           |
|                      |        |                         | n |           |
|                      |        |                         | t |           |
|                      |        |                         | a |           |
|                      |        |                         | n |           |
|                      |        |                         | d |           |
|                      |        |                         | E |           |
|                      |        |                         | f |           |
|                      |        |                         | f |           |
|                      |        |                         | e |           |
|                      |        |                         | c |           |
|                      |        |                         | t |           |
|                      |        |                         | i |           |
|                      |        |                         | v |           |
|                      |        |                         | e |           |
|                      |        |                         | M |           |
|                      |        |                         | i |           |
|                      |        |                         | s |           |
|                      |        |                         | s |           |
|                      |        |                         | i |           |
|                      |        |                         | o |           |
|                      |        |                         | n |           |
|                      |        |                         | A |           |
|                      |        |                         | c |           |
|                      |        |                         | c |           |
|                      |        |                         | o |           |
|                      |        |                         | m |           |
|                      |        |                         | p |           |
|                      |        |                         | l |           |
|                      |        |                         | i |           |
|                      |        |                         | s |           |
|                      |        |                         | h |           |
|                      |        |                         | m |           |
|                      |        |                         | e |           |
|                      |        |                         | n |           |
|                      |        |                         | t |           |
+----------------------+--------+-------------------------+---+-----------+
| *APPROACH :*         |        |                         |   |           |
|                      |        |                         |   |           |
| 1.  The Director's   |        |                         |   |           |
|     Office is        |        |                         |   |           |
|     responsible for  |        |                         |   |           |
|     S&T reporting    |        |                         |   |           |
|     with input from  |        |                         |   |           |
|     science          |        |                         |   |           |
|     departments.     |        |                         |   |           |
|     Data is gathered |        |                         |   |           |
|     using various    |        |                         |   |           |
|     sources such as  |        |                         |   |           |
|     FWP data, WFO,   |        |                         |   |           |
|     publications,    |        |                         |   |           |
|     end of run       |        |                         |   |           |
|     reports (NSRL,   |        |                         |   |           |
|     NSLS beamlines), |        |                         |   |           |
|     HR data. Quality |        |                         |   |           |
|     of research also |        |                         |   |           |
|     monitored        |        |                         |   |           |
|     directly by      |        |                         |   |           |
|     funding agencies |        |                         |   |           |
|     via FWPs, annual |        |                         |   |           |
|     reports,etc.     |        |                         |   |           |
+----------------------+--------+-------------------------+---+-----------+
| **Measures**         | **O    | ### Responsibility      |   | **Sch     |
|                      | ngoing |                         |   | edule/Due |
|                      | Maint  |                         |   | Date**    |
|                      | enance |                         |   |           |
|                      | (      |                         |   |           |
|                      | OM)/** |                         |   |           |
|                      |        |                         |   |           |
|                      | **Impr |                         |   |           |
|                      | ovemen |                         |   |           |
|                      | t(I)** |                         |   |           |
+----------------------+--------+-------------------------+---+-----------+
| Provide status       | OM     | Self Assessment Mgr     |   | 1^st^     |
| reports on S&T       |        | with Chairs and ALD     |   | Quarter   |
| performance, as      | OM     |                         |   | 08 for    |
| requested by the     |        | Principal Investigators |   | FY07      |
| Director's office    |        |                         |   | pe        |
|                      |        |                         |   | rformance |
| FWPs, WFO annual     |        |                         |   | (1^st^    |
| reports, etc         |        |                         |   | Qtr FY09  |
|                      |        |                         |   | for 08    |
|                      |        |                         |   | perf.)    |
|                      |        |                         |   |           |
|                      |        |                         |   | As        |
|                      |        |                         |   | required  |
|                      |        |                         |   | by agency |
+----------------------+--------+-------------------------+---+-----------+

## Attachment 1

**FY08 Self Assessment Activities**

+----------------------------------+-------+----------+------+-------+
| *ASSESSMENT CRITERIA:* 1.0       |       |          |      |       |
| Business and Operational Results |       |          |      |       |
+----------------------------------+-------+----------+------+-------+
| *OBJECTIVE:* Maintain and        |       |          | PEMP |       |
| improve the quality and quantity |       |          | 1.0  |       |
| of research conducted.           |       |          | Pro  |       |
|                                  |       |          | vide |       |
|                                  |       |          | for  |       |
|                                  |       |          | E    |       |
|                                  |       |          | ffic |       |
|                                  |       |          | ient |       |
|                                  |       |          | and  |       |
|                                  |       |          | E    |       |
|                                  |       |          | ffec |       |
|                                  |       |          | tive |       |
|                                  |       |          | Mis  |       |
|                                  |       |          | sion |       |
|                                  |       |          | Ac   |       |
|                                  |       |          | comp |       |
|                                  |       |          | lish |       |
|                                  |       |          | ment |       |
+----------------------------------+-------+----------+------+-------+
| *APPROACH :*                     |       |          |      |       |
|                                  |       |          |      |       |
| 1.  Use data from Strategic      |       |          |      |       |
|     Planning Committees to       |       |          |      |       |
|     develop maintain and improve |       |          |      |       |
|     the quality and quantity of  |       |          |      |       |
|     research, to include:        |       |          |      |       |
|                                  |       |          |      |       |
| ```{=html}                       |       |          |      |       |
| <!-- -->                         |       |          |      |       |
| ```                              |       |          |      |       |
| a)  Continue to promote and seek |       |          |      |       |
|     funding for bioenergy        |       |          |      |       |
|     research.                    |       |          |      |       |
|                                  |       |          |      |       |
| ```{=html}                       |       |          |      |       |
| <!-- -->                         |       |          |      |       |
| ```                              |       |          |      |       |
| a)  Continue to run and evaluate |       |          |      |       |
|     the NASA Space Radiation     |       |          |      |       |
|     Program                      |       |          |      |       |
|                                  |       |          |      |       |
| b)  Obtain funding for the       |       |          |      |       |
|     Imaging Program with the     |       |          |      |       |
|     Medical Department           |       |          |      |       |
+----------------------------------+-------+----------+------+-------+
| **Measures**                     | **On  | **       |      | **Sc  |
|                                  | going | Responsi |      | hedul |
|                                  | M     | bility** |      | e/Due |
|                                  | ainte |          |      | D     |
|                                  | nance |          |      | ate** |
|                                  | (OM)/ |          |      |       |
|                                  | I     |          |      |       |
|                                  | mprov |          |      |       |
|                                  | ement |          |      |       |
|                                  | (I)** |          |      |       |
+----------------------------------+-------+----------+------+-------+
| Continue to collect pilot data   | I     | Chair,   |      | On    |
| and seek core support for        |       | ALD,     |      | going |
| Biology as part of DOE Bioenergy | I     | Ap       |      |       |
| funding. Respond to RFPs when    |       | plicable |      | On    |
| applicable and related WFO.      | I     | P        |      | going |
|                                  |       | rincipal |      |       |
| Continue integration of imaging  | OM    | Inves    |      | On    |
| program (group meetings, cross   |       | tigators |      | going |
| training, etc) and seek funding. |       |          |      |       |
|                                  |       | ALD,     |      | On    |
| Increase Partnerships with other |       | Chairs   |      | going |
| institutions (eg Mt. Sinai)      |       | and      |      |       |
|                                  |       | Ap       |      |       |
| Continue to manage and evaluate  |       | plicable |      |       |
| the NSRL program and associated  |       | PIs      |      |       |
| research programs                |       |          |      |       |
|                                  |       | Chairs,  |      |       |
|                                  |       | Ap       |      |       |
|                                  |       | plicable |      |       |
|                                  |       | PIs      |      |       |
|                                  |       |          |      |       |
|                                  |       | ALD,     |      |       |
|                                  |       | Chairs   |      |       |
|                                  |       |          |      |       |
|                                  |       | ######   |      |       |
|                                  |       | Sutherla |      |       |
|                                  |       | nd, Guid |      |       |
|                                  |       | a, Chair |      |       |
|                                  |       | s {#suth |      |       |
|                                  |       | erland-g |      |       |
|                                  |       | uida-cha |      |       |
|                                  |       | irs .unn |      |       |
|                                  |       | umbered} |      |       |
+----------------------------------+-------+----------+------+-------+

##  

## Attachment 1

**FY08 Self Assessment Activities**

+---------------------------------+--------+-----------+------+-------+
| *ASSESSMENT CRITERIA:* Business |        |           |      |       |
| and Financial Management        |        |           |      |       |
+---------------------------------+--------+-----------+------+-------+
| *OBJECTIVE:* Manage financial   |        |           | PEMP |       |
| and business objectives of the  |        |           | 6    |       |
| Life Sciences Directorate.      |        |           | Del  |       |
|                                 |        |           | iver |       |
|                                 |        |           | Ef   |       |
|                                 |        |           | fici |       |
|                                 |        |           | ent, |       |
|                                 |        |           | Ef   |       |
|                                 |        |           | fect |       |
|                                 |        |           | ive, |       |
|                                 |        |           | and  |       |
|                                 |        |           | Re   |       |
|                                 |        |           | spon |       |
|                                 |        |           | sive |       |
|                                 |        |           | Busi |       |
|                                 |        |           | ness |       |
|                                 |        |           | Sys  |       |
|                                 |        |           | tems |       |
|                                 |        |           | and  |       |
|                                 |        |           | R    |       |
|                                 |        |           | esou |       |
|                                 |        |           | rces |       |
|                                 |        |           | that |       |
|                                 |        |           | En   |       |
|                                 |        |           | able |       |
|                                 |        |           | the  |       |
|                                 |        |           | Su   |       |
|                                 |        |           | cces |       |
|                                 |        |           | sful |       |
|                                 |        |           | Ach  |       |
|                                 |        |           | ieve |       |
|                                 |        |           | ment |       |
|                                 |        |           | of   |       |
|                                 |        |           | La   |       |
|                                 |        |           | bora |       |
|                                 |        |           | tory |       |
|                                 |        |           | Miss |       |
|                                 |        |           | ions |       |
+---------------------------------+--------+-----------+------+-------+
| *APPROACH :*                    |        |           |      |       |
|                                 |        |           |      |       |
| Monitoring and forecasting of   |        |           |      |       |
| budgets in order to manage the  |        |           |      |       |
| financial operations of the     |        |           |      |       |
| Directorate.                    |        |           |      |       |
+---------------------------------+--------+-----------+------+-------+
| **Measures**                    | **O    | **Respons |      | **Sc  |
|                                 | ngoing | ibility** |      | hedul |
|                                 | Maint  |           |      | e/Due |
|                                 | enance |           |      | D     |
|                                 | (      |           |      | ate** |
|                                 | OM)/** |           |      |       |
|                                 |        |           |      |       |
|                                 | **Impr |           |      |       |
|                                 | ovemen |           |      |       |
|                                 | t(I)** |           |      |       |
+---------------------------------+--------+-----------+------+-------+
| Budget Cycle:                   | 1.  OM | Budget    |      | 1     |
|                                 |        | Admin     |      | .  Ja |
| 1.  Budget Submission: finalize | ```{   | istrators |      | n-Mar |
|     current FY and plan next    | =html} |           |      |       |
|     two FY.                     | <!     | Budget    |      | ```{= |
|                                 | -- --> | Admin     |      | html} |
| ```{=html}                      | ```    | istrators |      | <!-   |
| <!-- -->                        | 1.  OM |           |      | - --> |
| ```                             |        |           |      | ```   |
| 1.  Budget Hearings: report     | 2.  OM |           |      | 1.    |
|     financial status to         |        |           |      |   May |
|     Director upon request.      | 3.  OM |           |      |       |
|                                 |        |           |      | 2.    |
| 2.  Plan next FY with best      | ```{   |           |      |   Jul |
|     estimate projections and    | =html} |           |      | y-Sep |
|     discuss with Chairs.        | <!     |           |      |       |
|                                 | -- --> |           |      | 3     |
| 3.  New FY budget and plans     | ```    |           |      | .  Oc |
|     based on actual budgets.    | 1.  OM |           |      | t-Dec |
|                                 |        |           |      |       |
| Additional                      | ```{   |           |      | ```{= |
| Reporting/Monitoring:           | =html} |           |      | html} |
|                                 | <!     |           |      | <!-   |
| 1.  Cost plan templates updated | -- --> |           |      | - --> |
|     and submitted to Budget     | ```    |           |      | ```   |
|     Office so they can manage   | 1.  OM |           |      | 1     |
|     the overhead units.         |        |           |      | .  Ju |
|                                 | 2.  OM |           |      | n-Aug |
| ```{=html}                      |        |           |      |       |
| <!-- -->                        | 3.  OM |           |      | ```{= |
| ```                             |        |           |      | html} |
| 1.  Monthly reports on project  | 4.  OM |           |      | <!-   |
|     status distributed to PIs.  |        |           |      | - --> |
|                                 | 5.  OM |           |      | ```   |
| 2.  Develop Monthly Reports by  |        |           |      | 1     |
|     Grant Year                  |        |           |      | .  Mo |
|                                 |        |           |      | nthly |
| 3.  Maintain Department burden  |        |           |      |       |
|     percentage rates (Admin,    |        |           |      | 2.    |
|     Space, Electric) the same   |        |           |      | Sept. |
|     or less than previous year. |        |           |      |       |
|                                 |        |           |      | 3     |
| 4.  Establish BLAF per diem     |        |           |      | .  On |
|     rates that follow BNL       |        |           |      | going |
|     escalation guidance         |        |           |      |       |
|                                 |        |           |      | 4     |
| 5.  Based on Lab charges for    |        |           |      | .  Au |
|     ITD and RCD (Instrument     |        |           |      | g-Oct |
|     Calibration and FSS),       |        |           |      |       |
|     establish recharge          |        |           |      | 5     |
|     mechanism to the Depts.     |        |           |      | .  Se |
|                                 |        |           |      | p-Nov |
| Note: Included in each of the   |        |           |      |       |
| Budget Cycle processes are the  |        |           |      |       |
| rates established for: Dept.    |        |           |      |       |
| Administrative Burden, BLAF     |        |           |      |       |
| Animal Per Diems, ITD           |        |           |      |       |
| Allocation Rate,                |        |           |      |       |
| Instrumentation Rate, Space and |        |           |      |       |
| Electric.                       |        |           |      |       |
+---------------------------------+--------+-----------+------+-------+

##  Attachment 1

**FY08 Self Assessment Activities**

+---------------------------------+--------+-----------+-----+--------+
| *ASSESSMENT CRITERIA:* 1.0      |        |           |     |        |
| Leadership Commitment and       |        |           |     |        |
| Involvement                     |        |           |     |        |
+---------------------------------+--------+-----------+-----+--------+
| *OBJECTIVE:* Enhance the        |        |           | 3.3 |        |
| effectiveness of Laboratory     |        |           | P   |        |
| communications and the          |        |           | rov |        |
| Laboratory's relationships with |        |           | ide |        |
| stakeholders.                   |        |           | Eff |        |
|                                 |        |           | ici |        |
|                                 |        |           | ent |        |
|                                 |        |           | and |        |
|                                 |        |           | Eff |        |
|                                 |        |           | ect |        |
|                                 |        |           | ive |        |
|                                 |        |           | Co  |        |
|                                 |        |           | mmu |        |
|                                 |        |           | nic |        |
|                                 |        |           | ati |        |
|                                 |        |           | ons |        |
|                                 |        |           | and |        |
|                                 |        |           | Re  |        |
|                                 |        |           | spo |        |
|                                 |        |           | nsi |        |
|                                 |        |           | ven |        |
|                                 |        |           | ess |        |
|                                 |        |           | to  |        |
|                                 |        |           | Cu  |        |
|                                 |        |           | sto |        |
|                                 |        |           | mer |        |
|                                 |        |           | Ne  |        |
|                                 |        |           | eds |        |
+---------------------------------+--------+-----------+-----+--------+
| *APPROACH :*                    |        |           |     |        |
|                                 |        |           |     |        |
| Continue to participate in      |        |           |     |        |
| BNL's community outreach        |        |           |     |        |
| program activities (Community   |        |           |     |        |
| Advisory Council, Envoy         |        |           |     |        |
| Program, Summer Sundays, other  |        |           |     |        |
| tours)                          |        |           |     |        |
|                                 |        |           |     |        |
| -Improve programs where         |        |           |     |        |
| applicable.                     |        |           |     |        |
|                                 |        |           |     |        |
| Continue to run the Nuclear     |        |           |     |        |
| Chemistry Summer School.        |        |           |     |        |
|                                 |        |           |     |        |
| Continue the RapiData course    |        |           |     |        |
| for x-ray crystallography data  |        |           |     |        |
| collection                      |        |           |     |        |
|                                 |        |           |     |        |
| Work with NASA to continue to   |        |           |     |        |
| develop NASA Summer School      |        |           |     |        |
|                                 |        |           |     |        |
| Seek DOE funding to conduct     |        |           |     |        |
| 2^nd^ annual circular dichroism |        |           |     |        |
| data collection using NSLS.     |        |           |     |        |
|                                 |        |           |     |        |
| Continue to participate, when   |        |           |     |        |
| applicable, in Community        |        |           |     |        |
| Advisory Council Meetings (ie.  |        |           |     |        |
| BLIP groundwater monitoring or  |        |           |     |        |
| research discovery or issue     |        |           |     |        |
| such as Biological Safety)      |        |           |     |        |
+---------------------------------+--------+-----------+-----+--------+
| **Measures**                    | **O    | **Respons |     | **     |
|                                 | ngoing | ibility** |     | Schedu |
|                                 | Maint  |           |     | le/Due |
|                                 | enance |           |     | Date** |
|                                 | (      |           |     |        |
|                                 | OM)/** |           |     |        |
|                                 |        |           |     |        |
|                                 | **Impr |           |     |        |
|                                 | ovemen |           |     |        |
|                                 | t(I)** |           |     |        |
+---------------------------------+--------+-----------+-----+--------+
| Run the Nuclear Chemistry       | OM     | Ferrieri  |     | 4^th^  |
| Summer School                   |        |           |     | qtr    |
|                                 | OM     | Guida     |     |        |
| Run the NASA summer school      |        |           |     | 4^th^  |
|                                 | OM     | ALD,      |     | qtr    |
| Host summer Sunday, invite ESH  |        | Chairs,   |     |        |
| staff and Ed programs to assist | OM     | Emrick    |     | 4^th^  |
|                                 |        | with      |     | qtr    |
| Run and evaluate RapiData       | OM     | CIGPA     |     | FY09   |
| Course                          |        |           |     | (note  |
|                                 |        | Sweet     |     | that   |
| Seek DOE funding and, if        |        |           |     | we     |
| obtained, run Circular          |        | J.        |     | rotate |
| Dichroism course                |        | Su        |     | out    |
|                                 |        | therland, |     | for    |
|                                 |        | Miller    |     | Summer |
|                                 |        | (NSLS)    |     | 08)    |
|                                 |        |           |     |        |
|                                 |        |           |     | 3^rd^  |
|                                 |        |           |     | qtr    |
|                                 |        |           |     |        |
|                                 |        |           |     | 4^th^  |
|                                 |        |           |     | qtr    |
+---------------------------------+--------+-----------+-----+--------+

##  

## Attachment 1

**FY08 Self Assessment Activities**

+---------------------------------+--------+---+---------------+-------+
| *ASSESSMENT CRITERIA:* 1.0      |        |   |               |       |
| Leadership Commitment and       |        |   |               |       |
| Involvement                     |        |   |               |       |
+---------------------------------+--------+---+---------------+-------+
| *OBJECTIVE:* Maintain and       |        |   | 7.0 Sustain   |       |
| Improve physical and            |        |   | Excellence in |       |
| computational resources and     |        |   | Operating,    |       |
| infrastructure                  |        |   | Maintaining,  |       |
|                                 |        |   | and Renewing  |       |
|                                 |        |   | the Facility  |       |
|                                 |        |   | and           |       |
|                                 |        |   | I             |       |
|                                 |        |   | nfrastructure |       |
|                                 |        |   | Portfolio to  |       |
|                                 |        |   | Meet          |       |
|                                 |        |   | Laboratory    |       |
|                                 |        |   | Needs/ EM     |       |
|                                 |        |   | Program       |       |
+---------------------------------+--------+---+---------------+-------+
| *APPROACH :*                    |        |   |               |       |
|                                 |        |   |               |       |
| Physical Infrastructure:        |        |   |               |       |
|                                 |        |   |               |       |
| Life Sciences needs to continue |        |   |               |       |
| to identify key areas (linked   |        |   |               |       |
| through strategic planning) for |        |   |               |       |
| infrastructure improvements and |        |   |               |       |
| apply for GPP funding or other  |        |   |               |       |
| applicable funding. FY08        |        |   |               |       |
| priorities are:                 |        |   |               |       |
|                                 |        |   |               |       |
| Biology:                        |        |   |               |       |
|                                 |        |   |               |       |
| -   Bldg 463 Office Space for   |        |   |               |       |
|     plant science and radiation |        |   |               |       |
|     biology programs            |        |   |               |       |
|                                 |        |   |               |       |
| -   Bldg 463, Lab 220           |        |   |               |       |
|     renovation                  |        |   |               |       |
|                                 |        |   |               |       |
| -   Bldg. 463, Lab 267/270      |        |   |               |       |
|                                 |        |   |               |       |
| Medical                         |        |   |               |       |
|                                 |        |   |               |       |
| -   Bldg. 490, 9-801            |        |   |               |       |
|                                 |        |   |               |       |
| -   Renovation of Bldg 901W     |        |   |               |       |
|                                 |        |   |               |       |
| See GPP funding program for     |        |   |               |       |
| more details.                   |        |   |               |       |
|                                 |        |   |               |       |
| We will also continue to        |        |   |               |       |
| conduct operational readiness   |        |   |               |       |
| reviews and exit readiness      |        |   |               |       |
| reviews on our major spaces.    |        |   |               |       |
|                                 |        |   |               |       |
| Computational Resources and     |        |   |               |       |
| Infrastructure:                 |        |   |               |       |
|                                 |        |   |               |       |
| -   Work with ITD to ensure     |        |   |               |       |
|     that all computers are      |        |   |               |       |
|     properly registered and IP  |        |   |               |       |
|     addresses are maintained up |        |   |               |       |
|     to date.                    |        |   |               |       |
+---------------------------------+--------+---+---------------+-------+
| **Measures**                    | **O    | * |               | **Sc  |
|                                 | ngoing | * |               | hedul |
|                                 | Maint  | R |               | e/Due |
|                                 | enance | e |               | D     |
|                                 | (      | s |               | ate** |
|                                 | OM)/** | p |               |       |
|                                 |        | o |               |       |
|                                 | **Impr | n |               |       |
|                                 | ovemen | s |               |       |
|                                 | t(I)** | i |               |       |
|                                 |        | b |               |       |
|                                 |        | i |               |       |
|                                 |        | l |               |       |
|                                 |        | i |               |       |
|                                 |        | t |               |       |
|                                 |        | y |               |       |
|                                 |        | * |               |       |
|                                 |        | * |               |       |
+---------------------------------+--------+---+---------------+-------+
| Physical Infrastructure:        | I      | A |               | 1^st^ |
|                                 |        | L |               | Qtr   |
| Start any FY08 funded projects  | I      | D |               |       |
| (see GPP program).              |        | , |               | 2^nd^ |
|                                 | OM     | C |               | Qtr   |
| Apply for FY09 funding          |        | h |               |       |
|                                 | OM     | a |               | On    |
| Conduct OREs/EREs for           |        | i |               | going |
| renovations                     |        | r |               |       |
|                                 |        | s |               | On    |
| Computing resources:            |        | , |               | going |
|                                 |        | S |               |       |
| 1\. Ensure new computers are    |        | p |               |       |
| registered and IP addresses are |        | a |               |       |
| maintained                      |        | c |               |       |
|                                 |        | e |               |       |
|                                 |        | C |               |       |
|                                 |        | o |               |       |
|                                 |        | n |               |       |
|                                 |        | t |               |       |
|                                 |        | a |               |       |
|                                 |        | c |               |       |
|                                 |        | t |               |       |
|                                 |        | s |               |       |
|                                 |        |   |               |       |
|                                 |        | C |               |       |
|                                 |        | h |               |       |
|                                 |        | a |               |       |
|                                 |        | i |               |       |
|                                 |        | r |               |       |
|                                 |        | s |               |       |
|                                 |        | , |               |       |
|                                 |        | B |               |       |
|                                 |        | l |               |       |
|                                 |        | d |               |       |
|                                 |        | g |               |       |
|                                 |        | M |               |       |
|                                 |        | g |               |       |
|                                 |        | r |               |       |
|                                 |        | s |               |       |
|                                 |        | , |               |       |
|                                 |        | W |               |       |
|                                 |        | C |               |       |
|                                 |        | M |               |       |
|                                 |        |   |               |       |
|                                 |        | E |               |       |
|                                 |        | S |               |       |
|                                 |        | H |               |       |
|                                 |        | M |               |       |
|                                 |        | g |               |       |
|                                 |        | r |               |       |
|                                 |        |   |               |       |
|                                 |        | I |               |       |
|                                 |        | T |               |       |
|                                 |        | D |               |       |
|                                 |        | , |               |       |
|                                 |        | I |               |       |
|                                 |        | T |               |       |
|                                 |        | L |               |       |
|                                 |        | i |               |       |
|                                 |        | a |               |       |
|                                 |        | i |               |       |
|                                 |        | s |               |       |
|                                 |        | o |               |       |
|                                 |        | n |               |       |
|                                 |        | a |               |       |
|                                 |        | n |               |       |
|                                 |        | d |               |       |
|                                 |        | C |               |       |
|                                 |        | h |               |       |
|                                 |        | a |               |       |
|                                 |        | i |               |       |
|                                 |        | r |               |       |
|                                 |        | s |               |       |
+---------------------------------+--------+---+---------------+-------+

### Attachment 1

## FY08 Self Assessment Activities

+--------------------+-------------+--------------------+-----+-------+
| *ASSESSMENT        |             |                    |     |       |
| CRITERIA:*         |             |                    |     |       |
| Leadership         |             |                    |     |       |
| Commitment and     |             |                    |     |       |
| Involvement        |             |                    |     |       |
+--------------------+-------------+--------------------+-----+-------+
| *OBJECTIVE:*       |             |                    | P   |       |
| Ensure management  |             |                    | EMP |       |
| oversight in       |             |                    | 4.0 |       |
| operations         |             |                    | P   |       |
|                    |             |                    | rov |       |
|                    |             |                    | ide |       |
|                    |             |                    | So  |       |
|                    |             |                    | und |       |
|                    |             |                    | and |       |
|                    |             |                    | Com |       |
|                    |             |                    | pet |       |
|                    |             |                    | ent |       |
|                    |             |                    | L   |       |
|                    |             |                    | ead |       |
|                    |             |                    | ers |       |
|                    |             |                    | hip |       |
|                    |             |                    | and |       |
|                    |             |                    | St  |       |
|                    |             |                    | ewa |       |
|                    |             |                    | rds |       |
|                    |             |                    | hip |       |
|                    |             |                    | of  |       |
|                    |             |                    | the |       |
|                    |             |                    | L   |       |
|                    |             |                    | abo |       |
|                    |             |                    | rat |       |
|                    |             |                    | ory |       |
|                    |             |                    |     |       |
|                    |             |                    | EM/ |       |
|                    |             |                    | OSH |       |
|                    |             |                    | P   |       |
|                    |             |                    | rog |       |
|                    |             |                    | ram |       |
+--------------------+-------------+--------------------+-----+-------+
| *APPROACH :*       |             |                    |     |       |
|                    |             |                    |     |       |
| Improve field      |             |                    |     |       |
| presence of        |             |                    |     |       |
| managers through:  |             |                    |     |       |
|                    |             |                    |     |       |
| > Senior Manager   |             |                    |     |       |
| > Work             |             |                    |     |       |
| > Observations     |             |                    |     |       |
| >                  |             |                    |     |       |
| > Annual           |             |                    |     |       |
| > Operations       |             |                    |     |       |
| > Management       |             |                    |     |       |
| > Review           |             |                    |     |       |
| >                  |             |                    |     |       |
| > Annual Budget    |             |                    |     |       |
| > hearings to      |             |                    |     |       |
| > update managers  |             |                    |     |       |
| > on status of     |             |                    |     |       |
| > current/future   |             |                    |     |       |
| > funding.         |             |                    |     |       |
| >                  |             |                    |     |       |
| > Periodic staff   |             |                    |     |       |
| > meetings,        |             |                    |     |       |
| > emails, other    |             |                    |     |       |
| > communications   |             |                    |     |       |
+--------------------+-------------+--------------------+-----+-------+
| **Measures**       | **Ongoing   | **Responsibility** |     | **Sc  |
|                    | Maintenance |                    |     | hedul |
|                    | (OM)/**     |                    |     | e/Due |
|                    |             |                    |     | D     |
|                    | **Impro     |                    |     | ate** |
|                    | vement(I)** |                    |     |       |
+--------------------+-------------+--------------------+-----+-------+
| Senior Manager     | I           | ALD, Chairmen,     |     | On    |
| Work Observations  |             | Level III Mgrs     |     | going |
|                    | OM          |                    |     |       |
| -   ALD to conduct |             | Chairs and ALD via |     | 4^th^ |
|     24 per year    | OM          | Ops Mgr.           |     | qtr   |
|                    |             |                    |     |       |
| -   BO and MO      | I           | ALD, Business Mgr, |     | 1^st^ |
|     Chairman each  |             | Chairs             |     | Qtr   |
|     12 per year    | I           |                    |     | 09    |
|                    |             | ALD (Institutional |     | (Oc   |
| -   Level III Mgrs |             | Committee)         |     | t-Nov |
|     2 per year     |             |                    |     | 2008) |
|                    |             | ALD (Institutional |     |       |
| Operations         |             | Committee)         |     | Upon  |
| Management Review  |             |                    |     | reqst |
| (roll up of FY08   |             |                    |     |       |
| performance)       |             |                    |     | 4^th^ |
|                    |             |                    |     | Qtr   |
| Budget Hearings as |             |                    |     |       |
| requested by DO    |             |                    |     | See   |
|                    |             |                    |     | BNL   |
| Ideas Program      |             |                    |     | POC   |
|                    |             |                    |     |       |
| Participate on     |             |                    |     |       |
| institutional      |             |                    |     |       |
| committee to       |             |                    |     |       |
| develop program.   |             |                    |     |       |
|                    |             |                    |     |       |
| Human Performance  |             |                    |     |       |
+--------------------+-------------+--------------------+-----+-------+

## Attachment 1

### 

### FY08 Self Assessment Activities

+----------------------------------------------+-----------------------+
| *ASSESSMENT CRITERIA:* 6.0 Compliance with   |                       |
| Laws Regulations and Contractual             |                       |
| Requirements                                 |                       |
|                                              |                       |
| 4.0 Process Management                       |                       |
+----------------------------------------------+-----------------------+
| *OBJECTIVE*: Achieve and maintain compliance | 5.0 Sustain           |
| with applicable laws and BNL regulations     | Excellence and        |
|                                              | Enhance Effectiveness |
|                                              | of Integrated Safety, |
|                                              | Health, and           |
|                                              | Environmental         |
|                                              | Protection            |
|                                              |                       |
|                                              | EM/OSH Program        |
+----------------------------------------------+-----------------------+

+-----------------------------------+-------+---------------+----------+
| *APPROACH :*                      |       |               |          |
|                                   |       |               |          |
| Establish and Maintain Overall    |       |               |          |
| Compliance in all areas by:       |       |               |          |
|                                   |       |               |          |
| 1.  Subject area publication and  |       |               |          |
|     change notifications,         |       |               |          |
|     identification and tracking   |       |               |          |
|     of implementation issues.     |       |               |          |
|                                   |       |               |          |
| ```{=html}                        |       |               |          |
| <!-- -->                          |       |               |          |
| ```                               |       |               |          |
| 1.  Tier 1s and work planning.    |       |               |          |
|                                   |       |               |          |
| 2.  Work Planning and Control     |       |               |          |
|     Processes                     |       |               |          |
|                                   |       |               |          |
| Environmental Compliance          |       |               |          |
|                                   |       |               |          |
| 1.  Conduct operations in         |       |               |          |
|     accordance with applicable    |       |               |          |
|     Environmental Subject Areas   |       |               |          |
|                                   |       |               |          |
| ```{=html}                        |       |               |          |
| <!-- -->                          |       |               |          |
| ```                               |       |               |          |
| 1.  Perform Environmental         |       |               |          |
|     Compliance Assessments        |       |               |          |
|     including process             |       |               |          |
|     evaluations, Tier Is and      |       |               |          |
|     participate in topical        |       |               |          |
|     assessments.                  |       |               |          |
|                                   |       |               |          |
| 2.  EMS Rep and ECR to            |       |               |          |
|     periodically review process   |       |               |          |
|     evaluations, experimental     |       |               |          |
|     reviews, and aspects analysis |       |               |          |
|     (at minimum annually)         |       |               |          |
|                                   |       |               |          |
| 3.  Improve RCRA Compliance by    |       |               |          |
|     tracking RCRA findings during |       |               |          |
|     Tier Is and reviewing with    |       |               |          |
|     PIs (e.g. during work         |       |               |          |
|     planning meetings)            |       |               |          |
|                                   |       |               |          |
| Radiation Control Program         |       |               |          |
|                                   |       |               |          |
| > 1\. Facility Support performs   |       |               |          |
| > assessment via Tier I           |       |               |          |
| > inspections and walk throughs   |       |               |          |
| > and rep quarterly assessments.  |       |               |          |
|                                   |       |               |          |
| 2\. Maintain isotope inventory    |       |               |          |
| for R&R group in order to ensure  |       |               |          |
| that inventories remain below the |       |               |          |
| non-reactor nuclear category 3    |       |               |          |
| level                             |       |               |          |
|                                   |       |               |          |
| 1.  Establish more efficient work |       |               |          |
|     process for the handling of   |       |               |          |
|     short-lived isotopes in 901   |       |               |          |
|     and 906.                      |       |               |          |
|                                   |       |               |          |
| Occupational Safety and Health:   |       |               |          |
|                                   |       |               |          |
| 1.  Chemical Safety performance:  |       |               |          |
|     conform to Chemical           |       |               |          |
|     Management System             |       |               |          |
|     requirements                  |       |               |          |
|                                   |       |               |          |
| ```{=html}                        |       |               |          |
| <!-- -->                          |       |               |          |
| ```                               |       |               |          |
| 1.  Participate in Topical        |       |               |          |
|     Assessments                   |       |               |          |
|                                   |       |               |          |
| Quality Management                |       |               |          |
|                                   |       |               |          |
| 1.  Participate in site-wide      |       |               |          |
|     topical assessments when      |       |               |          |
|     applicable.                   |       |               |          |
|                                   |       |               |          |
| ```{=html}                        |       |               |          |
| <!-- -->                          |       |               |          |
| ```                               |       |               |          |
| 1.  Implement revisions to        |       |               |          |
|     Internal Controlled Document  |       |               |          |
|     Control Subject Area.         |       |               |          |
|                                   |       |               |          |
| Tier I Program                    |       |               |          |
|                                   |       |               |          |
| 1.  Maintain Tier I program       |       |               |          |
|     including the regular         |       |               |          |
|     participation of ES&H subject |       |               |          |
|     matter experts.               |       |               |          |
|                                   |       |               |          |
| ```{=html}                        |       |               |          |
| <!-- -->                          |       |               |          |
| ```                               |       |               |          |
| 1.  Perform timely closeout of    |       |               |          |
|     Tier I findings               |       |               |          |
|                                   |       |               |          |
| 2.  Improve Tier I by focusing on |       |               |          |
|     negative trends               |       |               |          |
+-----------------------------------+-------+---------------+----------+
|                                   | **On  | **Res         | **Sche   |
|                                   | going | ponsibility** | dule/Due |
|                                   | M     |               | Date**   |
|                                   | ainte |               |          |
|                                   | nance |               |          |
|                                   | (O    |               |          |
|                                   | M)/** |               |          |
|                                   |       |               |          |
|                                   | **I   |               |          |
|                                   | mprov |               |          |
|                                   | ement |               |          |
|                                   | (I)** |               |          |
+-----------------------------------+-------+---------------+----------+
| **Objective: Overall ESH          |       |               |          |
| Compliance**                      |       |               |          |
+-----------------------------------+-------+---------------+----------+
| -   Tier I inspections            | I     | ESH Mgr       | >        |
|                                   |       |               |  Ongoing |
|     -   Closeout violations       |       |               |          |
|         within 90 days            |       |               | S        |
|                                   |       |               | ummarize |
|     -   Focus on OSHA             |       |               | to Mgmt  |
|         Particularly Hazardous    |       |               | at       |
|         Substances                |       |               | annual   |
|                                   |       |               | mgmt     |
|     -   For repeat RCRA           |       |               | review   |
|         violations meet with      |       |               |          |
|         staff and discuss         |       |               |          |
+-----------------------------------+-------+---------------+----------+
| -   Training Program (in addition | OM    | Training      | Ongoing  |
|     to T&Q Lab-Level Assessment   |       | Coo           |          |
|     Activities)                   |       | rd/staff/mgmt |          |
|                                   |       |               |          |
| ```{=html}                        |       |               |          |
| <!-- -->                          |       |               |          |
| ```                               |       |               |          |
| -   \% Job Training Assessments   |       |               |          |
|     reviewed to ensure            |       |               |          |
|     "up-to-date"                  |       |               |          |
|                                   |       |               |          |
| -   Maintain \>95% required       |       |               |          |
|     training complete for         |       |               |          |
|     employees.                    |       |               |          |
|                                   |       |               |          |
| -   \% JTAs linked to             |       |               |          |
|     visitors/guests as required.  |       |               |          |
|     (\>95% goal)                  |       |               |          |
+-----------------------------------+-------+---------------+----------+
| **Environmental Compliance**      |       |               |          |
+-----------------------------------+-------+---------------+----------+
| -   Participate in EWMSD Topical  | OM    | EWMSD Lead    | 4^th^    |
|     Assessments                   |       |               | Qtr      |
+-----------------------------------+-------+---------------+----------+
| -   Obtain and use funds to       | OM    | EMS           | Start    |
|     dispose of Radioactive        |       | R             | packing  |
|     Regulated Medical Waste       |       | ep/ECR/WMR/FS | 08       |
|     (occurs every 2-3 years)      |       |               |          |
|                                   |       |               | Ship     |
|                                   |       |               | FY09     |
+-----------------------------------+-------+---------------+----------+
| -   Continue to compile and       | OM    | ALD Special   | Ongoing  |
|     review environmental          |       | Asst, Line    | (report  |
|     monitoring data (ie BLIP      |       | Mgmt          | at Mgmt  |
|     Groundwater, air emissions)   |       |               | Review)  |
+-----------------------------------+-------+---------------+----------+
| -   Work to reduce air emissions  | I     | BLIP Coord,   | TB       |
|     by optimizing the             |       | ECR           | D-during |
|     efficiencies gained by using  |       |               | BLIP run |
|     the damper in BLIP that was   |       |               | season   |
|     installed last FY.            |       |               |          |
+-----------------------------------+-------+---------------+----------+
| -   Apply for air permit for BLIP | I     | Hooda,        | 2^nd^    |
|                                   |       | Mausner       | Qtr      |
+-----------------------------------+-------+---------------+----------+
| -   Maintain materials on         | OM    | ESH Mgr (via  | Ongoing  |
|     site-wide Comprehensive       |       | Tier Is)      |          |
|     Environmental Liabilities     | I     |               | 4^th^    |
|     List and Unwanted Materials   |       | 490 Bldg Mgr  | Qtr      |
|     and Chemicals List in a       | I     |               |          |
|     compliant state and work to   |       | 463 Bldg. Mgr | 4^th^    |
|     reduce footprint.             | I     |               | Qtr      |
|                                   |       | 801 Bldg Mgr  |          |
|     -   Use ALD funding to remove | I     |               | 4^th^    |
|         excess materials in at    |       | BES Spec'l    | Qtr      |
|         least one bin in 490      |       | Asst          |          |
|         Basement (Priority: Bin   |       |               | Ongoing  |
|         B, F, T, hot waste        |       |               |          |
|         sampling room, lead lined |       |               |          |
|         room 1^st^ floor)         |       |               |          |
|                                   |       |               |          |
|     -   Clean out high bay area   |       |               |          |
|         in 463                    |       |               |          |
|                                   |       |               |          |
|     -   Remove out-of-service     |       |               |          |
|         crane in Bldg. 801        |       |               |          |
|                                   |       |               |          |
|     -   Work with BES to dispose  |       |               |          |
|         of legacy materials in    |       |               |          |
|         901-in FY08 to continue   |       |               |          |
|         to clean out high bay     |       |               |          |
|         area and start area       |       |               |          |
|         surrounding cyclotron.    |       |               |          |
|         (as funding allows)       |       |               |          |
+-----------------------------------+-------+---------------+----------+
| -   Meet with waste generators    | I     | ECR/ESH       | Ongoing  |
|     who have repeat satellite     |       | Coo           |          |
|     area violations on Tier Is or |       | rd/Generators |          |
|     other walkthroughs.           |       |               |          |
+-----------------------------------+-------+---------------+----------+
| **OSH Compliance**                |       |               |          |
+-----------------------------------+-------+---------------+----------+
| -   Participate in SHSD topical   | OM    | SHSD Rep      | 2^nd^    |
|     assessments as applicable     |       | w/ESH Mgr     | Qtr      |
+-----------------------------------+-------+---------------+----------+
| -   Work with SHSD Rep to develop | I     | SHSD Rep with | 2^nd^    |
|     IH Monitoring plan for animal |       | ESH staff     | Qtr      |
|     allergens                     |       |               |          |
+-----------------------------------+-------+---------------+----------+
| -   Inventory non-UL listed       | I     | ESH           | 4^th^    |
|     equipment in Bldg.            |       | Coord/SHSD    | Qtr      |
|     901-Imaging areas             |       | Rep/AHJ       |          |
|                                   |       | qualifed      |          |
|                                   |       | individual(s) |          |
+-----------------------------------+-------+---------------+----------+
| -   Work on 851 Correct Action    | I     | ESH Coord     | Ongoing  |
|     plan once it's approved       |       |               | see plan |
|     (placeholder)                 |       |               |          |
+-----------------------------------+-------+---------------+----------+
| **Radiation Control**             |       |               |          |
+-----------------------------------+-------+---------------+----------+
| -   FS Rep quarterly assessments  | OM    | FS Rep        | Q        |
|                                   |       |               | uarterly |
+-----------------------------------+-------+---------------+----------+
| -   Perform annual Rad material   | OM    | Bldg. 801 Rad | 3^rd^    |
|     inventory Assessment in Bldg. |       | Inventory Mgr | Qtr      |
|     801                           |       |               |          |
+-----------------------------------+-------+---------------+----------+
| -   Maintain ALARA program-report | OM    | ESH Mgr       | Ongoing  |
|     to Mgmt at annual Ops Rev.    |       |               |          |
+-----------------------------------+-------+---------------+----------+
| -   Meet with FSS to establish    | I     | FS w/PET      | Ongoing  |
|     more efficient work processes |       | staff         |          |
|     for the short-lived isotopes  |       |               |          |
|     used at 901 and 906.          |       |               |          |
+-----------------------------------+-------+---------------+----------+

##  Attachment 1

**FY08 Self Assessment Activities**

+----------------------------------------------------+-----------------+
| *ASSESSMENT CRITERIA 4.0* Process Management       |                 |
+----------------------------------------------------+-----------------+
| *OBJECTIVE:* Conduct operations in accordance with | PEMP 5.2        |
| the Expectations of the BNL's Management Systems   | Provide         |
| to improve environmental performance and worker    | Efficient and   |
| safety and health.                                 | Effective       |
|                                                    | Implementation  |
|                                                    | of Integrated   |
|                                                    | Safety, Health  |
|                                                    | and             |
|                                                    | Environmental   |
|                                                    | Management      |
|                                                    |                 |
|                                                    | EM/OSH Program  |
+----------------------------------------------------+-----------------+

+-----------------------------+------+---+------------+-------------------+
| *APPROACH :*                |      |   |            |                   |
|                             |      |   |            |                   |
| Integrated Safety           |      |   |            |                   |
| Management:                 |      |   |            |                   |
|                             |      |   |            |                   |
| 1\. Implement the ISM       |      |   |            |                   |
| Corrective Action Plan.     |      |   |            |                   |
|                             |      |   |            |                   |
| Work Planning and Control   |      |   |            |                   |
| Management System           |      |   |            |                   |
|                             |      |   |            |                   |
| Experimental Review         |      |   |            |                   |
|                             |      |   |            |                   |
| 1.  Maintain a              |      |   |            |                   |
|     Directorate-level       |      |   |            |                   |
|     experimental review     |      |   |            |                   |
|     program in accordance   |      |   |            |                   |
|     with SBMS Work Planning |      |   |            |                   |
|     and Control Subject     |      |   |            |                   |
|     Areas including decay   |      |   |            |                   |
|     in storage, and path of |      |   |            |                   |
|     disposal reviews.       |      |   |            |                   |
|                             |      |   |            |                   |
| Routine Work Planning       |      |   |            |                   |
|                             |      |   |            |                   |
| 1.  Maintain, the           |      |   |            |                   |
|     Directorate-level work  |      |   |            |                   |
|     planning program in     |      |   |            |                   |
|     accordance with         |      |   |            |                   |
|     Laboratory requirements |      |   |            |                   |
|                             |      |   |            |                   |
| ```{=html}                  |      |   |            |                   |
| <!-- -->                    |      |   |            |                   |
| ```                         |      |   |            |                   |
| 1.  Improve program by      |      |   |            |                   |
|     incorporating JRAs into |      |   |            |                   |
|     work planning processes |      |   |            |                   |
|                             |      |   |            |                   |
| > Environmental Management: |      |   |            |                   |
|                             |      |   |            |                   |
| 1.  Continue to develop and |      |   |            |                   |
|     improve EMS             |      |   |            |                   |
|                             |      |   |            |                   |
| ```{=html}                  |      |   |            |                   |
| <!-- -->                    |      |   |            |                   |
| ```                         |      |   |            |                   |
| 1.  Perform required EMS    |      |   |            |                   |
|     Assessments as per      |      |   |            |                   |
|     Environmental           |      |   |            |                   |
|     Assessments Subject     |      |   |            |                   |
|     Area                    |      |   |            |                   |
|                             |      |   |            |                   |
| 2.  Maintain ISO14001       |      |   |            |                   |
|     registration for        |      |   |            |                   |
|     Directorate by          |      |   |            |                   |
|     successfully            |      |   |            |                   |
|     participating in a      |      |   |            |                   |
|     surveillance audit by   |      |   |            |                   |
|     an outside registrar    |      |   |            |                   |
|     (to be funded by the    |      |   |            |                   |
|     BNL EMS project).       |      |   |            |                   |
|                             |      |   |            |                   |
| Emergency Management        |      |   |            |                   |
|                             |      |   |            |                   |
| 1\. Prepare for and         |      |   |            |                   |
| participate in DOE          |      |   |            |                   |
| Emergency Management        |      |   |            |                   |
| Assessment.                 |      |   |            |                   |
|                             |      |   |            |                   |
| Facility Safety             |      |   |            |                   |
|                             |      |   |            |                   |
| 1\. Upgrade BLIP SAD to     |      |   |            |                   |
| meet Accelerator Safety     |      |   |            |                   |
| rqmts.                      |      |   |            |                   |
|                             |      |   |            |                   |
| 2\. Apply for air permit    |      |   |            |                   |
| for BLIP.                   |      |   |            |                   |
|                             |      |   |            |                   |
| 3\. Upgrade shielding at    |      |   |            |                   |
| TPL.                        |      |   |            |                   |
|                             |      |   |            |                   |
| Occupational Safety and     |      |   |            |                   |
| Health:                     |      |   |            |                   |
|                             |      |   |            |                   |
| 1.  Maintain ISO18001 by    |      |   |            |                   |
|     successfully            |      |   |            |                   |
|     participating in        |      |   |            |                   |
|     surveillance audit by   |      |   |            |                   |
|     external registrar      |      |   |            |                   |
|     (funded by BNL OHSAS    |      |   |            |                   |
|     project).               |      |   |            |                   |
|                             |      |   |            |                   |
| ```{=html}                  |      |   |            |                   |
| <!-- -->                    |      |   |            |                   |
| ```                         |      |   |            |                   |
| 1.  Improve worker safety   |      |   |            |                   |
|     and health, reduce      |      |   |            |                   |
|     potential for injury    |      |   |            |                   |
|                             |      |   |            |                   |
| > Records Management        |      |   |            |                   |
|                             |      |   |            |                   |
| 1.  Maintain all vital      |      |   |            |                   |
|     records up to date.     |      |   |            |                   |
|                             |      |   |            |                   |
| ```{=html}                  |      |   |            |                   |
| <!-- -->                    |      |   |            |                   |
| ```                         |      |   |            |                   |
| 1.  Maintain all            |      |   |            |                   |
|     Departmental business   |      |   |            |                   |
|     and ESH operations and  |      |   |            |                   |
|     Chair records in the    |      |   |            |                   |
|     upgraded Records        |      |   |            |                   |
|     Manager System.         |      |   |            |                   |
|                             |      |   |            |                   |
| 2.  Ensure all Principal    |      |   |            |                   |
|     Investigators have a    |      |   |            |                   |
|     records inventory.      |      |   |            |                   |
+-----------------------------+------+---+------------+-------------------+
| **Measures**                | *    |   | **Respon   | **Schedule/Due    |
|                             | *Ong |   | sibility** | Date**            |
|                             | oing |   |            |                   |
|                             | Mai  |   |            |                   |
|                             | nten |   |            |                   |
|                             | ance |   |            |                   |
|                             | (OM  |   |            |                   |
|                             | )/** |   |            |                   |
|                             |      |   |            |                   |
|                             | **   |   |            |                   |
|                             | Impr |   |            |                   |
|                             | ovem |   |            |                   |
|                             | ent( |   |            |                   |
|                             | I)** |   |            |                   |
+-----------------------------+------+---+------------+-------------------+
| ####### I                   |      |   |            |                   |
| ntegrated Safety Management |      |   |            |                   |
+-----------------------------+------+---+------------+-------------------+
| -   Implement ISM           | I    |   | ISM POC    | See ATS           |
|     Improvement Plan as     |      |   |            |                   |
|     applicable              |      |   |            |                   |
+-----------------------------+------+---+------------+-------------------+
| -   Address ISM audit       | I    |   | ISM POC,   | See ATS (once     |
|     findings as applicable  |      |   | staff      | plan is issued)   |
|     (placeholder)           |      |   |            |                   |
+-----------------------------+------+---+------------+-------------------+
| ########                    |      |   |            |                   |
| # Work Planning and Control |      |   |            |                   |
+-----------------------------+------+---+------------+-------------------+
| -   Work Planning           | I    | E |            | See ISM           |
|                             |      | S |            | Improvement       |
|     -   Experimental and    |      | R |            | project           |
|         Routine WP process  |      | C |            |                   |
|                             |      | / |            |                   |
|         -   Work with POC   |      | W |            |                   |
|             to implement    |      | C |            |                   |
|             ISM corrective  |      | M |            |                   |
|             action plan.    |      | w |            |                   |
|                             |      | i |            |                   |
|                             |      | t |            |                   |
|                             |      | h |            |                   |
|                             |      | P |            |                   |
|                             |      | O |            |                   |
|                             |      | C |            |                   |
+-----------------------------+------+---+------------+-------------------+
| -   Routine Work            | *    | W |            | 1^st^ qtr         |
|                             | *I** | C |            |                   |
|     -   Train all WCC to    |      | C |            |                   |
|         the revised Subject |      |   |            |                   |
|         Area                |      |   |            |                   |
+-----------------------------+------+---+------------+-------------------+
| ####### Facility Safety     |      |   |            |                   |
+-----------------------------+------+---+------------+-------------------+
| -   Accelerator Safety      | *    | B |            | 6/1/08 Draft      |
|                             | *I** | L |            |                   |
| > \- BLIP Safety Analysis   |      | I |            | 7/15/08 Internal  |
| > Document                  |      | P |            | MO review         |
|                             |      | F |            |                   |
|                             |      | a |            | 8/30/08 Submit    |
|                             |      | c |            | BNL ESH Comm.     |
|                             |      | S |            |                   |
|                             |      | u |            |                   |
|                             |      | p |            |                   |
|                             |      | v |            |                   |
|                             |      | s |            |                   |
|                             |      | r |            |                   |
|                             |      | / |            |                   |
|                             |      | E |            |                   |
|                             |      | S |            |                   |
|                             |      | H |            |                   |
|                             |      | C |            |                   |
|                             |      | o |            |                   |
|                             |      | o |            |                   |
|                             |      | r |            |                   |
|                             |      | d |            |                   |
+-----------------------------+------+---+------------+-------------------+
| -   Upgrade TPL shielding   | *    | T |            | 4^th^ Qtr         |
|                             | *I** | P |            |                   |
|                             |      | L |            |                   |
|                             |      | F |            |                   |
|                             |      | a |            |                   |
|                             |      | c |            |                   |
|                             |      | S |            |                   |
|                             |      | p |            |                   |
|                             |      | v |            |                   |
|                             |      | s |            |                   |
|                             |      | r |            |                   |
|                             |      | / |            |                   |
|                             |      | E |            |                   |
|                             |      | S |            |                   |
|                             |      | H |            |                   |
|                             |      | C |            |                   |
|                             |      | o |            |                   |
|                             |      | o |            |                   |
|                             |      | r |            |                   |
|                             |      | d |            |                   |
+-----------------------------+------+---+------------+-------------------+
| **Emergency Management**    |      |   |            |                   |
+-----------------------------+------+---+------------+-------------------+
| -   Review emergency        | *    | L |            | 2^nd^ Qtr         |
|     programs to ensure      | *I** | E |            |                   |
|     compliance with SBMS.   |      | C |            |                   |
|                             |      | s |            |                   |
+-----------------------------+------+---+------------+-------------------+
| -   Participate in DOE      | *    | L |            | 3^rd^ Qtr         |
|     Emergency Mgmt Audit    | *I** | E |            |                   |
|                             |      | C |            |                   |
|                             |      | s |            |                   |
|                             |      | / |            |                   |
|                             |      | s |            |                   |
|                             |      | t |            |                   |
|                             |      | a |            |                   |
|                             |      | f |            |                   |
|                             |      | f |            |                   |
+-----------------------------+------+---+------------+-------------------+
| ##### Envir                 |      |   |            |                   |
| onmental Management Program |      |   |            |                   |
+-----------------------------+------+---+------------+-------------------+
| -   Zero non-conformances   | OM   |   | ECR Lead   | 2^nd^ Qtr         |
|     in BNL's Assessment of  |      |   | w/ESH      |                   |
|     Environmental           |      |   | staff,     |                   |
|     Management System in    |      |   | others     |                   |
|     accordance with the     |      |   |            |                   |
|     "Environmental          |      |   |            |                   |
|     Assessments" Subject    |      |   |            |                   |
|     Area.                   |      |   |            |                   |
+-----------------------------+------+---+------------+-------------------+
| -   Perform a management    | OM   |   | EMS Rep    | 4^th^ Qtr         |
|     review of EMS in        |      |   | w/Mgrs     |                   |
|     accordance with the     |      |   |            |                   |
|     "Environmental          |      |   |            |                   |
|     Assessments" Subject    |      |   |            |                   |
|     Area.                   |      |   |            |                   |
+-----------------------------+------+---+------------+-------------------+
| -   Zero non-conformances   | I    |   | EMS Rep    | 3^rd^ Qtr         |
|     in ISO14001             |      |   |            |                   |
|     registration audit      |      |   |            |                   |
+-----------------------------+------+---+------------+-------------------+
| -   Participate in          | I    |   | EMS Rep    | 1^st^ Qtr--P2     |
|     Pollution Prevention    |      |   | lead       | Proposals (see    |
|     program by              |      |   |            | call)             |
|                             |      |   |            |                   |
|     -   Submit at least 2   |      |   |            | 4^th^ Qtr --      |
|         pollution           |      |   |            | success story     |
|         prevention proposal |      |   |            |                   |
|         (one of which is    |      |   |            |                   |
|         targeted at         |      |   |            |                   |
|         greenhouse gas      |      |   |            |                   |
|         emissions and one   |      |   |            |                   |
|         on chemical         |      |   |            |                   |
|         reduction) and 1    |      |   |            |                   |
|         success story       |      |   |            |                   |
+-----------------------------+------+---+------------+-------------------+
| -   Encourage staff to use  | I    |   | EMS Rep/IT | 2^nd^ Qtr         |
|     energy saver modes for  |      |   | Liaison    |                   |
|     computers/monitors as   |      |   |            |                   |
|     appropriate (email or   |      |   |            |                   |
|     newsletter)             |      |   |            |                   |
+-----------------------------+------+---+------------+-------------------+
| ## OSH Management Program   |      |   |            |                   |
+-----------------------------+------+---+------------+-------------------+
| -   Maintain OHSAS 18001    | OM   |   | OHSAS      | 1^st^ Qtr         |
|     system                  |      |   | Team,      |                   |
|                             |      |   | staff      | 2^nd^ Qtr         |
|     -   Review              |      |   |            |                   |
|         documentation       |      |   |            | 3^rd^ Qtr         |
|                             |      |   |            |                   |
|     -   Participate in      |      |   |            |                   |
|         Internal OSHAS      |      |   |            |                   |
|         assessment          |      |   |            |                   |
|                             |      |   |            |                   |
|     -   Participate in      |      |   |            |                   |
|         external registrar  |      |   |            |                   |
|         audit               |      |   |            |                   |
+-----------------------------+------+---+------------+-------------------+
| -   Maintain and improve    | I    |   | OHSAS      | 1^st^ Qtr         |
|     OHSAS System            |      |   | Team,      |                   |
|                             |      |   | staff      | 4^th^ Qtr         |
|     -   Review 50% of       |      |   |            |                   |
|         existing JRAs       |      |   |            | At annual review  |
|         (start with oldest) |      |   |            | of ESRs for       |
|                             |      |   |            | ongoing. Upon     |
| -   Communicate JRAs via    |      |   |            | submission of new |
|     Work Planning by        |      |   |            | ESRs/WPs          |
|     incorporation into ESRs |      |   |            |                   |
|     and WPs                 |      |   |            |                   |
+-----------------------------+------+---+------------+-------------------+
| -   Participate in Safety   | I    |   | Staff, ESH | 4^th^ Qtr (see    |
|     Solutions Program in an |      |   | Mgr        | call for          |
|     effort to reduce injury |      |   |            | proposals)        |
|     potential.              |      |   |            |                   |
|                             |      |   |            |                   |
|     -   Submit 2 proposals  |      |   |            |                   |
|         and/or 2 success    |      |   |            |                   |
|         stories             |      |   |            |                   |
+-----------------------------+------+---+------------+-------------------+
| -   Improve OSH             | I    |   | All staff  | Ongoing           |
|     Performance:            |      |   |            |                   |
|                             |      |   |            |                   |
|     -   Hands on training   |      |   |            |                   |
|         by Vet for any      |      |   |            |                   |
|         worker who has no   |      |   |            |                   |
|         experience in       |      |   |            |                   |
|         animal handling.    |      |   |            |                   |
|                             |      |   |            |                   |
|     -   Refresher training  |      |   |            |                   |
|         by Vet for any      |      |   |            |                   |
|         worker who reports  |      |   |            |                   |
|         an animal bite.     |      |   |            |                   |
+-----------------------------+------+---+------------+-------------------+
| -   Improve PPE             | I    |   | ESH Coord  | 1^st^-4^th^ Qtr   |
|                             |      |   | Lead/Staff |                   |
| > To decrease the number of |      |   |            |                   |
| > clinic reports for        |      |   |            |                   |
| > cuts/scratches, evaluate  |      |   |            |                   |
| > glove options and provide |      |   |            |                   |
| > choices to staff (ie for  |      |   |            |                   |
| > animal handling,          |      |   |            |                   |
| > cryogens, etc).           |      |   |            |                   |
+-----------------------------+------+---+------------+-------------------+
| ####### Quality Assurance   |      |   |            |                   |
+-----------------------------+------+---+------------+-------------------+
| -   Records Management      | OM   |   | Records    | 4^th^ Qtr         |
|                             |      |   | Reps with  |                   |
| ```{=html}                  |      |   | staff      |                   |
| <!-- -->                    |      |   |            |                   |
| ```                         |      |   |            |                   |
| -   Maintain all vital      |      |   |            |                   |
|     records up to date.     |      |   |            |                   |
|     (ongoing)               |      |   |            |                   |
|                             |      |   |            |                   |
| -   Ensure all Principal    |      |   |            |                   |
|     Investigators have a    |      |   |            |                   |
|     records inventory.      |      |   |            |                   |
|     (Ongoing)               |      |   |            |                   |
+-----------------------------+------+---+------------+-------------------+
| -   Document Control        | I    |   | EMS        | 4^th^ Qtr         |
|                             |      |   | Rep/OHSAS  | complete          |
|     -   Implement changes   |      |   | Rep/QA     |                   |
|         to Internal         |      |   |            |                   |
|         Controlled          |      |   |            |                   |
|         Documents Subject   |      |   |            |                   |
|         Area                |      |   |            |                   |
+-----------------------------+------+---+------------+-------------------+

**Attachment 1**

**FY08 Self Assessment Activities**

## 

+-----------------------+--------------+---------------+---+----------+
| *ASSESSMENT           |              |               |   |          |
| CRITERIA*:            |              |               |   |          |
| Operational           |              |               |   |          |
| Excellence/Process    |              |               |   |          |
| Management            |              |               |   |          |
+-----------------------+--------------+---------------+---+----------+
| *OBJECTIVE A*chieve   |              |               | 5 |          |
| integration of        |              |               | . |          |
| environmental         |              |               | 0 |          |
| stewardship,          |              |               | S |          |
| radiological, and     |              |               | u |          |
| safety management     |              |               | s |          |
| into all facets of    |              |               | t |          |
| the Laboratory's      |              |               | a |          |
| missions, and manage  |              |               | i |          |
| programs and          |              |               | n |          |
| operations in a       |              |               | E |          |
| manner that protects  |              |               | x |          |
| ecosystem, workers,   |              |               | c |          |
| and public health     |              |               | e |          |
|                       |              |               | l |          |
|                       |              |               | l |          |
|                       |              |               | e |          |
|                       |              |               | n |          |
|                       |              |               | c |          |
|                       |              |               | e |          |
|                       |              |               | a |          |
|                       |              |               | n |          |
|                       |              |               | d |          |
|                       |              |               | E |          |
|                       |              |               | n |          |
|                       |              |               | h |          |
|                       |              |               | a |          |
|                       |              |               | n |          |
|                       |              |               | c |          |
|                       |              |               | e |          |
|                       |              |               | E |          |
|                       |              |               | f |          |
|                       |              |               | f |          |
|                       |              |               | e |          |
|                       |              |               | c |          |
|                       |              |               | t |          |
|                       |              |               | i |          |
|                       |              |               | v |          |
|                       |              |               | e |          |
|                       |              |               | n |          |
|                       |              |               | e |          |
|                       |              |               | s |          |
|                       |              |               | s |          |
|                       |              |               | o |          |
|                       |              |               | f |          |
|                       |              |               | I |          |
|                       |              |               | n |          |
|                       |              |               | t |          |
|                       |              |               | e |          |
|                       |              |               | g |          |
|                       |              |               | r |          |
|                       |              |               | a |          |
|                       |              |               | t |          |
|                       |              |               | e |          |
|                       |              |               | d |          |
|                       |              |               | S |          |
|                       |              |               | a |          |
|                       |              |               | f |          |
|                       |              |               | e |          |
|                       |              |               | t |          |
|                       |              |               | y |          |
|                       |              |               | , |          |
|                       |              |               | H |          |
|                       |              |               | e |          |
|                       |              |               | a |          |
|                       |              |               | l |          |
|                       |              |               | t |          |
|                       |              |               | h |          |
|                       |              |               | , |          |
|                       |              |               | a |          |
|                       |              |               | n |          |
|                       |              |               | d |          |
|                       |              |               | E |          |
|                       |              |               | n |          |
|                       |              |               | v |          |
|                       |              |               | i |          |
|                       |              |               | r |          |
|                       |              |               | o |          |
|                       |              |               | n |          |
|                       |              |               | m |          |
|                       |              |               | e |          |
|                       |              |               | n |          |
|                       |              |               | t |          |
|                       |              |               | a |          |
|                       |              |               | l |          |
|                       |              |               | P |          |
|                       |              |               | r |          |
|                       |              |               | o |          |
|                       |              |               | t |          |
|                       |              |               | e |          |
|                       |              |               | c |          |
|                       |              |               | t |          |
|                       |              |               | i |          |
|                       |              |               | o |          |
|                       |              |               | n |          |
|                       |              |               |   |          |
|                       |              |               | O |          |
|                       |              |               | S |          |
|                       |              |               | H |          |
|                       |              |               | P |          |
|                       |              |               | r |          |
|                       |              |               | o |          |
|                       |              |               | g |          |
|                       |              |               | r |          |
|                       |              |               | a |          |
|                       |              |               | m |          |
+-----------------------+--------------+---------------+---+----------+
| *APPROACH :*          |              |               |   |          |
|                       |              |               |   |          |
| BNL must comply with  |              |               |   |          |
| the 440.1A DOE Order  |              |               |   |          |
| on work with          |              |               |   |          |
| Biological and        |              |               |   |          |
| Etiologic agents      |              |               |   |          |
| (which includes       |              |               |   |          |
| references to NIH     |              |               |   |          |
| rDNA guidelines, USDA |              |               |   |          |
| and CDC Select Agent  |              |               |   |          |
| Programs) and the     |              |               |   |          |
| requirements of the   |              |               |   |          |
| Biological Weapons    |              |               |   |          |
| Convention. To do     |              |               |   |          |
| this we developed a   |              |               |   |          |
| Biological Safety     |              |               |   |          |
| Subject Area, revised |              |               |   |          |
| our Institutional     |              |               |   |          |
| Biosafety Committee   |              |               |   |          |
| (IBC), took an        |              |               |   |          |
| inventory of all      |              |               |   |          |
| existing agents and   |              |               |   |          |
| incorporated any      |              |               |   |          |
| newly identified      |              |               |   |          |
| using existing        |              |               |   |          |
| systems (Experimental |              |               |   |          |
| Safety Review). We,   |              |               |   |          |
| in Life Sciences (in  |              |               |   |          |
| particular Biology),  |              |               |   |          |
| must continue to work |              |               |   |          |
| closely with Safety   |              |               |   |          |
| and Health Services   |              |               |   |          |
| Division (SHSD) to    |              |               |   |          |
| maintain the system.  |              |               |   |          |
|                       |              |               |   |          |
| We must also continue |              |               |   |          |
| to maintain the       |              |               |   |          |
| Regulated Etiologic   |              |               |   |          |
| Agent database with   |              |               |   |          |
| S&HSD. We are subject |              |               |   |          |
| to audits, both       |              |               |   |          |
| announced and         |              |               |   |          |
| unannounced,          |              |               |   |          |
+-----------------------+--------------+---------------+---+----------+
| **Measures**          | **Ongoing    | **Res         |   | **Sche   |
|                       | Maintenance  | ponsibility** |   | dule/Due |
|                       | (OM)/**      |               |   | Date**   |
|                       |              |               |   |          |
|                       | **Impr       |               |   |          |
|                       | ovement(I)** |               |   |          |
+-----------------------+--------------+---------------+---+----------+
| 1.  Maintain          | OM           | S&HSD Lead,   |   | Ongoing  |
|     inventory of all  |              | Life Sciences |   |          |
|     regulated         | OM           | will do       |   | Ongoing  |
|     etiologic agents  |              | during IBC    |   |          |
|     (as required in   | OM           | review        |   | (Next    |
|     440.1A)           |              |               |   | Site     |
|                       | I            | IBC           |   | visit:   |
| ```{=html}            |              | Coordi        |   | \~6/09)  |
| <!-- -->              |              | nator/PIs/RFO |   |          |
| ```                   |              |               |   | 2^nd^    |
| 1.  BNL maintains a   |              | IBC           |   | Qtr      |
|     select agent      |              | Co            |   | (when    |
|     registration.     |              | ordinator/IBC |   | r        |
|     There's a         |              | Chair/BWC     |   | equested |
|     required          |              | contact       |   | by DOE)  |
|     site-visit once   |              |               |   |          |
|     during 3yr        |              | SHSD Lead     |   | 2^nd^    |
|     registration      |              | w/IBC Reps    |   | Qtr      |
|     period. Other     |              |               |   |          |
|     visits may be     |              |               |   |          |
|     unannounced. Goal |              |               |   |          |
|     is to have no     |              |               |   |          |
|     interruption in   |              |               |   |          |
|     registration due  |              |               |   |          |
|     to audit          |              |               |   |          |
|     findings.         |              |               |   |          |
|                       |              |               |   |          |
| 2.  BNL is required   |              |               |   |          |
|     to submit         |              |               |   |          |
|     Confidence        |              |               |   |          |
|     Building Measures |              |               |   |          |
|     annually          |              |               |   |          |
|     (Biological       |              |               |   |          |
|     Weapons           |              |               |   |          |
|     Convention Data)  |              |               |   |          |
|     to DOE (NA-241).  |              |               |   |          |
|                       |              |               |   |          |
| 3.  Review and        |              |               |   |          |
|     Revise, as        |              |               |   |          |
|     needed, the       |              |               |   |          |
|     Biologicals In    |              |               |   |          |
|     Research Subject  |              |               |   |          |
|     Area              |              |               |   |          |
+-----------------------+--------------+---------------+---+----------+

##  Attachment 1

### FY08 Self Assessment Activities

+--------------------------+----------------+-----------+---+----------+
| *ASSESSMENT CRITERIA:*   |                |           |   |          |
| Process                  |                |           |   |          |
| Management/Operational   |                |           |   |          |
| Excellence               |                |           |   |          |
+--------------------------+----------------+-----------+---+----------+
| *OBJECTIVE*: Effectively |                |           | 2 |          |
| and efficiently manage   |                |           | . |          |
| Clinical Research Center |                |           | 3 |          |
| operations including the |                |           | P |          |
| oversight of the         |                |           | r |          |
| Controlled Substance     |                |           | o |          |
| Program.                 |                |           | v |          |
|                          |                |           | i |          |
|                          |                |           | d |          |
|                          |                |           | e |          |
|                          |                |           | E |          |
|                          |                |           | f |          |
|                          |                |           | f |          |
|                          |                |           | i |          |
|                          |                |           | c |          |
|                          |                |           | i |          |
|                          |                |           | e |          |
|                          |                |           | n |          |
|                          |                |           | t |          |
|                          |                |           | a |          |
|                          |                |           | n |          |
|                          |                |           | d |          |
|                          |                |           | E |          |
|                          |                |           | f |          |
|                          |                |           | f |          |
|                          |                |           | e |          |
|                          |                |           | c |          |
|                          |                |           | t |          |
|                          |                |           | i |          |
|                          |                |           | v |          |
|                          |                |           | e |          |
|                          |                |           | O |          |
|                          |                |           | p |          |
|                          |                |           | e |          |
|                          |                |           | r |          |
|                          |                |           | a |          |
|                          |                |           | t |          |
|                          |                |           | i |          |
|                          |                |           | o |          |
|                          |                |           | n |          |
|                          |                |           | o |          |
|                          |                |           | f |          |
|                          |                |           | F |          |
|                          |                |           | a |          |
|                          |                |           | c |          |
|                          |                |           | i |          |
|                          |                |           | l |          |
|                          |                |           | i |          |
|                          |                |           | t |          |
|                          |                |           | i |          |
|                          |                |           | e |          |
|                          |                |           | s |          |
+--------------------------+----------------+-----------+---+----------+
| *APPROACH :*             |                |           |   |          |
|                          |                |           |   |          |
| Periodically Assess      |                |           |   |          |
| Clinical Research Center |                |           |   |          |
| operations. Utilize      |                |           |   |          |
| independent subject      |                |           |   |          |
| matter experts, as       |                |           |   |          |
| appropriate, in the      |                |           |   |          |
| conduct of selected      |                |           |   |          |
| assessments              |                |           |   |          |
|                          |                |           |   |          |
| -   Ensure clearly       |                |           |   |          |
|     define roles and     |                |           |   |          |
|     responsibilities.    |                |           |   |          |
|                          |                |           |   |          |
| -   Maintain and         |                |           |   |          |
|     continually improve  |                |           |   |          |
|     operational          |                |           |   |          |
|     procedures           |                |           |   |          |
|                          |                |           |   |          |
| -   Conduct quarterly    |                |           |   |          |
|     compliance (Stony    |                |           |   |          |
|     Brook U.) and        |                |           |   |          |
|     periodic system      |                |           |   |          |
|     assessments of the   |                |           |   |          |
|     CRC operation        |                |           |   |          |
|                          |                |           |   |          |
| -   Effectively and      |                |           |   |          |
|     efficiently closeout |                |           |   |          |
|     corrective and       |                |           |   |          |
|     improvement actions  |                |           |   |          |
|     identified through   |                |           |   |          |
|     assessment           |                |           |   |          |
|     activities           |                |           |   |          |
|                          |                |           |   |          |
| -   Assess the           |                |           |   |          |
|     controlled substance |                |           |   |          |
|     program as per CRC   |                |           |   |          |
|     Policies and         |                |           |   |          |
|     Procedures           |                |           |   |          |
|                          |                |           |   |          |
| These operations are     |                |           |   |          |
| also audited by external |                |           |   |          |
| parties (e.g. JCAHO,     |                |           |   |          |
| FDA, DEA). The audits    |                |           |   |          |
| can be unannounced.      |                |           |   |          |
| Those that are scheduled |                |           |   |          |
| on a regular basis are:  |                |           |   |          |
|                          |                |           |   |          |
| -   JCAHO Survey --      |                |           |   |          |
|     every 3 years. Next  |                |           |   |          |
|     one is due           |                |           |   |          |
|     August 2008. At the  |                |           |   |          |
|     midpoint there is a  |                |           |   |          |
|     self-assessment      |                |           |   |          |
|     performed by the     |                |           |   |          |
|     Institution and      |                |           |   |          |
|     reviewed by JCAHO    |                |           |   |          |
|     via a                |                |           |   |          |
|     teleconference.      |                |           |   |          |
|     JCAHO can also send  |                |           |   |          |
|     auditors unannounced |                |           |   |          |
|     at anytime.          |                |           |   |          |
|                          |                |           |   |          |
| -   Controlled           |                |           |   |          |
|     Substances: DEA      |                |           |   |          |
|     inventory every two  |                |           |   |          |
|     years.               |                |           |   |          |
+--------------------------+----------------+-----------+---+----------+
| **Measures**             | **Ongoing      | **Respons |   | **Sche   |
|                          | Maintenance    | ibility** |   | dule/Due |
|                          | (OM)/**        |           |   | Date**   |
|                          |                |           |   |          |
|                          | **Im           |           |   |          |
|                          | provement(I)** |           |   |          |
+--------------------------+----------------+-----------+---+----------+
| Conduct compliance       | OM             | 1.  SBU   |   | 1.       |
| assessments of CRC       |                |     C     |   |  Ongoing |
| including the review of  |                | ompliance |   |          |
| the subject records.     |                |           |   | ``       |
|                          |                |    Coord. |   | `{=html} |
| 1.  Assess               |                |           |   | <!-- --> |
|     implementation of    |                | 2.  CRC   |   | ```      |
|     protocols            |                |           |   | 1.       |
|     (evaluation of       |                |   Manager |   |  Ongoing |
|     adverse              |                |           |   |          |
|     events/violations).  |                | 3.  CRC   |   | 2        |
|                          |                |           |   | .  4^th^ |
| ```{=html}               |                |   Manager |   |     Qtr  |
| <!-- -->                 |                |     with  |   |          |
| ```                      |                |     P     |   | 3.  Aug  |
| 1.  Perform assessment   |                | harmacist |   |     2008 |
|     of the CRC program   |                |           |   |          |
|     and provide report   |                | 4.  CRC   |   | 4.  May, |
|     to management.       |                |     Man   |   |     2009 |
|                          |                | ager/Line |   |          |
| 2.  Assess the status of |                |     Mgrs  |   | > 6\.    |
|     the controlled       |                |           |   | > May,   |
|     substance program    |                | 5.  CRC   |   | > 2008   |
|                          |                |     Man   |   |          |
| 3.  JCAHO Survey         |                | ager/Line |   |          |
|                          |                |     Mgrs  |   |          |
| 4.  JCAHO                |                |           |   |          |
|     Self-Assessment      |                | 6.  CRC   |   |          |
|                          |                |     Mgr/P |   |          |
| 5.  DEA Controlled       |                | harmacist |   |          |
|     Substance Inventory  |                |           |   |          |
+--------------------------+----------------+-----------+---+----------+

## Attachment 1

### FY08 Self Assessment Activities

+-----------------------+---------------+---------------+---+----------+
| *ASSESSMENT           |               |               |   |          |
| CRITERIA:* Process    |               |               |   |          |
| Management            |               |               |   |          |
+-----------------------+---------------+---------------+---+----------+
| *OBJECTIVE*: Maintain |               |               | 3 |          |
| and Improve Isotope   |               |               | . |          |
| Production Program    |               |               | 0 |          |
|                       |               |               | P |          |
|                       |               |               | r |          |
|                       |               |               | o |          |
|                       |               |               | v |          |
|                       |               |               | i |          |
|                       |               |               | d |          |
|                       |               |               | e |          |
|                       |               |               | E |          |
|                       |               |               | f |          |
|                       |               |               | f |          |
|                       |               |               | e |          |
|                       |               |               | c |          |
|                       |               |               | t |          |
|                       |               |               | i |          |
|                       |               |               | v |          |
|                       |               |               | e |          |
|                       |               |               | a |          |
|                       |               |               | n |          |
|                       |               |               | d |          |
|                       |               |               | E |          |
|                       |               |               | f |          |
|                       |               |               | f |          |
|                       |               |               | i |          |
|                       |               |               | c |          |
|                       |               |               | i |          |
|                       |               |               | e |          |
|                       |               |               | n |          |
|                       |               |               | t |          |
|                       |               |               | S |          |
|                       |               |               | c |          |
|                       |               |               | i |          |
|                       |               |               | e |          |
|                       |               |               | n |          |
|                       |               |               | c |          |
|                       |               |               | e |          |
|                       |               |               | a |          |
|                       |               |               | n |          |
|                       |               |               | d |          |
|                       |               |               | T |          |
|                       |               |               | e |          |
|                       |               |               | c |          |
|                       |               |               | h |          |
|                       |               |               | n |          |
|                       |               |               | o |          |
|                       |               |               | l |          |
|                       |               |               | o |          |
|                       |               |               | g |          |
|                       |               |               | y |          |
|                       |               |               | P |          |
|                       |               |               | r |          |
|                       |               |               | o |          |
|                       |               |               | g |          |
|                       |               |               | r |          |
|                       |               |               | a |          |
|                       |               |               | m |          |
|                       |               |               | M |          |
|                       |               |               | a |          |
|                       |               |               | n |          |
|                       |               |               | a |          |
|                       |               |               | g |          |
|                       |               |               | e |          |
|                       |               |               | m |          |
|                       |               |               | e |          |
|                       |               |               | n |          |
|                       |               |               | t |          |
+-----------------------+---------------+---------------+---+----------+
| *APPROACH :*          |               |               |   |          |
|                       |               |               |   |          |
| As per, Office of     |               |               |   |          |
| Isotopes Program,     |               |               |   |          |
| Production Site       |               |               |   |          |
| Managers are          |               |               |   |          |
| responsible for       |               |               |   |          |
| performing an annual  |               |               |   |          |
| management assessment |               |               |   |          |
| of activities.        |               |               |   |          |
| Processes being       |               |               |   |          |
| assessed should       |               |               |   |          |
| include:              |               |               |   |          |
|                       |               |               |   |          |
| -   Strategic         |               |               |   |          |
|     planning:         |               |               |   |          |
|     production site   |               |               |   |          |
|     manager           |               |               |   |          |
|     participates in   |               |               |   |          |
|     semi-annual       |               |               |   |          |
|     strategic         |               |               |   |          |
|     planning sessions |               |               |   |          |
|     for program,      |               |               |   |          |
|     assistance in the |               |               |   |          |
|     preparation of a  |               |               |   |          |
|     5yr business plan |               |               |   |          |
|     which includes a  |               |               |   |          |
|     yr 1 budget,      |               |               |   |          |
|     quarterly         |               |               |   |          |
|     progress reports  |               |               |   |          |
|     and an annual     |               |               |   |          |
|     report are        |               |               |   |          |
|     submitted which   |               |               |   |          |
|     includes          |               |               |   |          |
|     strategic         |               |               |   |          |
|     planning as well  |               |               |   |          |
|     as budget and     |               |               |   |          |
|     productivity      |               |               |   |          |
|     reporting         |               |               |   |          |
|     (against          |               |               |   |          |
|     performance       |               |               |   |          |
|     measures)         |               |               |   |          |
|                       |               |               |   |          |
| -   Organizational    |               |               |   |          |
|     interfaces:       |               |               |   |          |
|     Weekly planning   |               |               |   |          |
|     meetings with AGS |               |               |   |          |
|     during runs, ad   |               |               |   |          |
|     hoc meetings with |               |               |   |          |
|     Plant             |               |               |   |          |
|     Engineering,      |               |               |   |          |
|                       |               |               |   |          |
|  Collider-Accelerator |               |               |   |          |
|     and others        |               |               |   |          |
|                       |               |               |   |          |
| -   Cost control:     |               |               |   |          |
|     quarterly         |               |               |   |          |
|     reporting to      |               |               |   |          |
|     funding agency    |               |               |   |          |
|     and budgeting     |               |               |   |          |
|     process.          |               |               |   |          |
|                       |               |               |   |          |
| -   Use of            |               |               |   |          |
|     performance       |               |               |   |          |
|     indicators: in    |               |               |   |          |
|     annual report     |               |               |   |          |
|                       |               |               |   |          |
| -   Training and      |               |               |   |          |
|     Qualifications:   |               |               |   |          |
|     As part of BNL    |               |               |   |          |
|     Training and      |               |               |   |          |
|     Qualifications    |               |               |   |          |
|     program.          |               |               |   |          |
|                       |               |               |   |          |
| -   Supervisory       |               |               |   |          |
|     oversight and     |               |               |   |          |
|     support: this is  |               |               |   |          |
|     reviewed as part  |               |               |   |          |
|     of performance    |               |               |   |          |
|     evaluation of     |               |               |   |          |
|     managers.         |               |               |   |          |
|                       |               |               |   |          |
| -   Customer          |               |               |   |          |
|     feedback:         |               |               |   |          |
|     Maintain a        |               |               |   |          |
|     tracking system   |               |               |   |          |
|     for customer      |               |               |   |          |
|     feedback.         |               |               |   |          |
|                       |               |               |   |          |
| Also, Current Good    |               |               |   |          |
| Manufacturing         |               |               |   |          |
| Practices (cGMP)      |               |               |   |          |
| which has been        |               |               |   |          |
| successfully          |               |               |   |          |
| implemented for this  |               |               |   |          |
| group, has an         |               |               |   |          |
| assessment            |               |               |   |          |
| requirement.          |               |               |   |          |
|                       |               |               |   |          |
| Most of these         |               |               |   |          |
| self-assessment       |               |               |   |          |
| activities are        |               |               |   |          |
| already discussed in  |               |               |   |          |
| this self-assessment  |               |               |   |          |
| plan. The measures    |               |               |   |          |
| listed below are only |               |               |   |          |
| for those activities  |               |               |   |          |
| exclusive to the      |               |               |   |          |
| Isotope Production    |               |               |   |          |
| Facility. For more    |               |               |   |          |
| details on DOEs       |               |               |   |          |
| Programmatic          |               |               |   |          |
| Performance measures  |               |               |   |          |
| for this program see  |               |               |   |          |
| Production Site       |               |               |   |          |
| Manager.              |               |               |   |          |
+-----------------------+---------------+---------------+---+----------+
| **Measures**          | **Ongoing     | **Res         |   | **Sche   |
|                       | Maintenance   | ponsibility** |   | dule/Due |
|                       | (OM)/**       |               |   | Date**   |
|                       |               |               |   |          |
|                       | **Imp         |               |   |          |
|                       | rovement(I)** |               |   |          |
+-----------------------+---------------+---------------+---+----------+
| 5 Yr Business plan    | OM            | > Production  |   | >        |
|                       |               | > site        |   |  8/30/08 |
| 1yr annual report     | OM            | > manager     |   | > (5yr   |
|                       |               | >             |   | > plan)  |
| 1 yr budget           | OM            | > Production  |   | >        |
|                       |               | > site        |   | >        |
| Monthly reports       | OM            | > manager     |   | 10/31/07 |
|                       |               | >             |   | >        |
| FWPs                  | OM            | > Production  |   |  (annual |
|                       |               | > site        |   | > rep)   |
| Quarterly Meetings    | OM            | > manager     |   | >        |
| w/DOE                 |               | > w/Budget    |   | >        |
|                       | OM            | >             |   | 10/31/07 |
| Proposed business     |               | Administrator |   | > (1 yr  |
| plan (Sept/Oct)       |               | >             |   | > budg.) |
|                       |               | > Production  |   |          |
| Budget (Mar/Apr)      |               | > site        |   | Monthly  |
|                       |               | > manager     |   |          |
| DOE programmatic      |               | > w/Budget    |   | Annual   |
| issues (June)         |               | >             |   | (F       |
|                       |               | Administrator |   | ebruary) |
| Conduct CGMP annual   |               | >             |   |          |
| assessment            |               | > Production  |   | Q        |
|                       |               | > site        |   | uarterly |
|                       |               | > manager     |   | (\~Mar,  |
|                       |               | >             |   | Jun,     |
|                       |               | > Production  |   | Sept)    |
|                       |               | > site        |   |          |
|                       |               | > manager     |   | July     |
|                       |               |               |   | 2008     |
|                       |               | R&R Group QA  |   |          |
|                       |               | rep           |   |          |
+-----------------------+---------------+---------------+---+----------+

## Attachment 1

## FY08 Self Assessment Activities

+-----------------------+---------------+---------------+---+-------------+
| *ASSESSMENT           |               |               |   |             |
| CRITERIA:*            |               |               |   |             |
| Operational           |               |               |   |             |
| Excellence and        |               |               |   |             |
| Process Mgmt          |               |               |   |             |
+-----------------------+---------------+---------------+---+-------------+
| *OBJECTIVE*:          |               |               |   | 2.3 Provide |
| Effectively and       |               |               |   | Efficient   |
| efficiently manage    |               |               |   | and         |
| the Brookhaven        |               |               |   | Effective   |
| Laboratory Animal     |               |               |   | Operation   |
| Facility              |               |               |   | of          |
|                       |               |               |   | Facilities  |
+-----------------------+---------------+---------------+---+-------------+
| *APPROACH :*          |               |               |   |             |
|                       |               |               |   |             |
| The Medical           |               |               |   |             |
| Department is         |               |               |   |             |
| responsible for the   |               |               |   |             |
| Institution's         |               |               |   |             |
| Brookhaven Laboratory |               |               |   |             |
| Animal Facility       |               |               |   |             |
| (BLAF). In this role  |               |               |   |             |
| the Department has    |               |               |   |             |
| the responsibility    |               |               |   |             |
| for managing it       |               |               |   |             |
| effectively and       |               |               |   |             |
| efficiently. The      |               |               |   |             |
| Institutional Animal  |               |               |   |             |
| Use and Care          |               |               |   |             |
| Committee provides    |               |               |   |             |
| oversight for this    |               |               |   |             |
| facility. To do this  |               |               |   |             |
| the IACUC assesses    |               |               |   |             |
| the BLAF              |               |               |   |             |
| semi-annually using   |               |               |   |             |
| guidance from the     |               |               |   |             |
| "Guide for Care and   |               |               |   |             |
| Use of Laboratory     |               |               |   |             |
| Animals". The         |               |               |   |             |
| facility is           |               |               |   |             |
| accredited by AAALAC  |               |               |   |             |
| and must undergo      |               |               |   |             |
| audits every 3yrs.    |               |               |   |             |
| The USDA and NYS Dept |               |               |   |             |
| of Health also        |               |               |   |             |
| inspect this facility |               |               |   |             |
| on a regular basis    |               |               |   |             |
| (both announced and   |               |               |   |             |
| unannounced visits).  |               |               |   |             |
+-----------------------+---------------+---------------+---+-------------+
| **Measures**          | **Ongoing     | **Res         | * |             |
|                       | Maintenance   | ponsibility** | * |             |
|                       | (OM)/**       |               | S |             |
|                       |               |               | c |             |
|                       | **Imp         |               | h |             |
|                       | rovement(I)** |               | e |             |
|                       |               |               | d |             |
|                       |               |               | u |             |
|                       |               |               | l |             |
|                       |               |               | e |             |
|                       |               |               | / |             |
|                       |               |               | D |             |
|                       |               |               | u |             |
|                       |               |               | e |             |
|                       |               |               | D |             |
|                       |               |               | a |             |
|                       |               |               | t |             |
|                       |               |               | e |             |
|                       |               |               | * |             |
|                       |               |               | * |             |
+-----------------------+---------------+---------------+---+-------------+
| #######               | OM            | BLAF Mgr,     | S |             |
|                       |               | Vet, Line     | u |             |
| 1.  Association for   | OM            | Mgrs, IACUC   | m |             |
|     Assessment and    |               |               | m |             |
|     Accreditation of  | OM            | BLAF Mgr,     | e |             |
|     Laboratory Animal |               | Vet, Line     | r |             |
|     Care (AAALAC).    | OM            | Mgr.          | , |             |
|     Certifies BLAF    |               |               | 2 |             |
|     every 3 yrs.      |               | BLAF Mgr,     | 0 |             |
|                       |               | Vet, Line Mgr | 0 |             |
| ```{=html}            |               |               | 8 |             |
| <!-- -->              |               | IACUC         |   |             |
| ```                   |               |               | 1 |             |
| 1.  USDA inspection.  |               |               | - |             |
|     Unannounced 1-2   |               |               | 2 |             |
|     times/year.       |               |               | t |             |
|                       |               |               | i |             |
| 2.  NYS Dept. of      |               |               | m |             |
|     Health            |               |               | e |             |
|                       |               |               | s |             |
| ####### 4.            |               |               | p |             |
|  IACUC, semi-annually |               |               | e |             |
|                       |               |               | r |             |
|                       |               |               | y |             |
|                       |               |               | e |             |
|                       |               |               | a |             |
|                       |               |               | r |             |
|                       |               |               | . |             |
|                       |               |               |   |             |
|                       |               |               | A |             |
|                       |               |               | n |             |
|                       |               |               | n |             |
|                       |               |               | u |             |
|                       |               |               | a |             |
|                       |               |               | l |             |
|                       |               |               | ( |             |
|                       |               |               | e |             |
|                       |               |               | s |             |
|                       |               |               | t |             |
|                       |               |               | . |             |
|                       |               |               | F |             |
|                       |               |               | e |             |
|                       |               |               | b |             |
|                       |               |               | , |             |
|                       |               |               | 2 |             |
|                       |               |               | 0 |             |
|                       |               |               | 0 |             |
|                       |               |               | 8 |             |
|                       |               |               | ) |             |
|                       |               |               |   |             |
|                       |               |               | 2 |             |
|                       |               |               | t |             |
|                       |               |               | i |             |
|                       |               |               | m |             |
|                       |               |               | e |             |
|                       |               |               | s |             |
|                       |               |               | p |             |
|                       |               |               | e |             |
|                       |               |               | r |             |
|                       |               |               | y |             |
|                       |               |               | e |             |
|                       |               |               | a |             |
|                       |               |               | r |             |
+-----------------------+---------------+---------------+---+-------------+

+-------------------+-----------------------------+--------+---+---------+
| **Attachment 2**  |                             |        |   |         |
|                   |                             |        |   |         |
| **ES&H Program    |                             |        |   |         |
| Improvement       |                             |        |   |         |
| Plan**            |                             |        |   |         |
|                   |                             |        |   |         |
| # Life Sci        |                             |        |   |         |
| ences Directorate |                             |        |   |         |
|                   |                             |        |   |         |
| The action plans  |                             |        |   |         |
| for achieving the |                             |        |   |         |
| Goals and         |                             |        |   |         |
| Objectives for    |                             |        |   |         |
| ESH management    |                             |        |   |         |
| have been         |                             |        |   |         |
| incorporated into |                             |        |   |         |
| this FY08         |                             |        |   |         |
| Self-Assessment   |                             |        |   |         |
| plan. The plan    |                             |        |   |         |
| describes the     |                             |        |   |         |
| Approach          |                             |        |   |         |
| (Targets),        |                             |        |   |         |
| Measures (means   |                             |        |   |         |
| of achieving the  |                             |        |   |         |
| goals), the       |                             |        |   |         |
| timeframe         |                             |        |   |         |
| (completion       |                             |        |   |         |
| dates), and lead  |                             |        |   |         |
| (responsible      |                             |        |   |         |
| person/position). |                             |        |   |         |
| This attachment   |                             |        |   |         |
| is intended to    |                             |        |   |         |
| summarize the     |                             |        |   |         |
| improvement       |                             |        |   |         |
| related goals for |                             |        |   |         |
| the ESH program.  |                             |        |   |         |
| The Directorate's |                             |        |   |         |
| normal operating  |                             |        |   |         |
| budgets will be   |                             |        |   |         |
| used unless there |                             |        |   |         |
| is need for       |                             |        |   |         |
| additional funds. |                             |        |   |         |
| If so, Activity   |                             |        |   |         |
| Data Sheets,      |                             |        |   |         |
| Safety Solutions  |                             |        |   |         |
| or Pollution      |                             |        |   |         |
| Prevention        |                             |        |   |         |
| proposals will be |                             |        |   |         |
| submitted. Those  |                             |        |   |         |
| cases where       |                             |        |   |         |
| special funding   |                             |        |   |         |
| is being used are |                             |        |   |         |
| noted as such.    |                             |        |   |         |
| Goals and         |                             |        |   |         |
| objectives are    |                             |        |   |         |
| set by reviewing  |                             |        |   |         |
| critical          |                             |        |   |         |
| outcomes,         |                             |        |   |         |
| environmental     |                             |        |   |         |
| priorities,       |                             |        |   |         |
| significant       |                             |        |   |         |
| aspects in the    |                             |        |   |         |
| Directorate, and  |                             |        |   |         |
| the results of    |                             |        |   |         |
| past management   |                             |        |   |         |
| reviews and       |                             |        |   |         |
| assessments.      |                             |        |   |         |
+-------------------+-----------------------------+--------+---+---------+
| #### **Target**   | #### **Actions**            | **     |   | #####   |
|                   |                             | Person |   | #### Co |
|                   |                             | R      |   | mpletio |
|                   |                             | espons |   | n Dates |
|                   |                             | ible** |   |         |
+-------------------+-----------------------------+--------+---+---------+
| ##                |                             |        |   |         |
| ####### Objective |                             |        |   |         |
| : Improve ISM and |                             |        |   |         |
|  ESH Management S |                             |        |   |         |
| ystem Performance |                             |        |   |         |
+-------------------+-----------------------------+--------+---+---------+
| Improve ISM       | Implement ISM Improvement   | ISM    | S |         |
| program           | Plan, as applicable         | POCs   | e |         |
|                   |                             |        | e |         |
|                   |                             |        | A |         |
|                   |                             |        | T |         |
|                   |                             |        | S |         |
+-------------------+-----------------------------+--------+---+---------+
|                   | Implement ISM audit         | ISM    | S |         |
|                   | corrective actions as       | POCs   | e |         |
|                   | applicable.                 |        | e |         |
|                   |                             |        | A |         |
|                   |                             |        | T |         |
|                   |                             |        | S |         |
|                   |                             |        | I |         |
|                   |                             |        | S |         |
|                   |                             |        | M |         |
|                   |                             |        | c |         |
|                   |                             |        | o |         |
|                   |                             |        | r |         |
|                   |                             |        | r |         |
|                   |                             |        | e |         |
|                   |                             |        | c |         |
|                   |                             |        | t |         |
|                   |                             |        | i |         |
|                   |                             |        | v |         |
|                   |                             |        | e |         |
|                   |                             |        | a |         |
|                   |                             |        | c |         |
|                   |                             |        | t |         |
|                   |                             |        | i |         |
|                   |                             |        | o |         |
|                   |                             |        | n |         |
|                   |                             |        | p |         |
|                   |                             |        | l |         |
|                   |                             |        | a |         |
|                   |                             |        | n |         |
|                   |                             |        | f |         |
|                   |                             |        | o |         |
|                   |                             |        | r |         |
|                   |                             |        | s |         |
|                   |                             |        | c |         |
|                   |                             |        | h |         |
|                   |                             |        | e |         |
|                   |                             |        | d |         |
|                   |                             |        | u |         |
|                   |                             |        | l |         |
|                   |                             |        | e |         |
+-------------------+-----------------------------+--------+---+---------+
| Improve Facility  | Upgrade TPL shielding       | M      | 4 |         |
| Safety Program    |                             | ausner | ^ |         |
|                   |                             |        | t |         |
|                   |                             |        | h |         |
|                   |                             |        | ^ |         |
|                   |                             |        | Q |         |
|                   |                             |        | t |         |
|                   |                             |        | r |         |
+-------------------+-----------------------------+--------+---+---------+
|                   | Revise the BLIP SAD to meet | Ma     | 6 |         |
|                   | Accelerator Safety Subject  | usner, | / |         |
|                   | Area requirements.          | Moss,  | 1 |         |
|                   |                             | Bullis | / |         |
|                   |                             |        | 0 |         |
|                   |                             |        | 8 |         |
|                   |                             |        | D |         |
|                   |                             |        | r |         |
|                   |                             |        | a |         |
|                   |                             |        | f |         |
|                   |                             |        | t |         |
|                   |                             |        |   |         |
|                   |                             |        | 7 |         |
|                   |                             |        | / |         |
|                   |                             |        | 1 |         |
|                   |                             |        | 5 |         |
|                   |                             |        | / |         |
|                   |                             |        | 0 |         |
|                   |                             |        | 8 |         |
|                   |                             |        | I |         |
|                   |                             |        | n |         |
|                   |                             |        | t |         |
|                   |                             |        | e |         |
|                   |                             |        | r |         |
|                   |                             |        | n |         |
|                   |                             |        | a |         |
|                   |                             |        | l |         |
|                   |                             |        | M |         |
|                   |                             |        | O |         |
|                   |                             |        | r |         |
|                   |                             |        | e |         |
|                   |                             |        | v |         |
|                   |                             |        | i |         |
|                   |                             |        | e |         |
|                   |                             |        | w |         |
|                   |                             |        |   |         |
|                   |                             |        | 8 |         |
|                   |                             |        | / |         |
|                   |                             |        | 3 |         |
|                   |                             |        | 0 |         |
|                   |                             |        | / |         |
|                   |                             |        | 0 |         |
|                   |                             |        | 8 |         |
|                   |                             |        | S |         |
|                   |                             |        | u |         |
|                   |                             |        | b |         |
|                   |                             |        | m |         |
|                   |                             |        | i |         |
|                   |                             |        | t |         |
|                   |                             |        | B |         |
|                   |                             |        | N |         |
|                   |                             |        | L |         |
|                   |                             |        | E |         |
|                   |                             |        | S |         |
|                   |                             |        | H |         |
|                   |                             |        | C |         |
|                   |                             |        | o |         |
|                   |                             |        | m |         |
|                   |                             |        | m |         |
|                   |                             |        | . |         |
+-------------------+-----------------------------+--------+---+---------+
| Emergency         | Review emergency program to | LECs   | 2 |         |
| Management        | ensure compliance with SBMS |        | ^ |         |
|                   |                             |        | n |         |
|                   |                             |        | d |         |
|                   |                             |        | ^ |         |
|                   |                             |        | Q |         |
|                   |                             |        | t |         |
|                   |                             |        | r |         |
+-------------------+-----------------------------+--------+---+---------+
|                   | Participate in DOE          | LE     | 3 |         |
|                   | Emergency Mgmt Audit        | Cs/Sta | ^ |         |
|                   |                             | ff/POC | r |         |
|                   |                             |        | d |         |
|                   |                             |        | ^ |         |
|                   |                             |        | Q |         |
|                   |                             |        | t |         |
|                   |                             |        | r |         |
+-------------------+-----------------------------+--------+---+---------+
| Improve OSH       | Update 50% JRAs and FRAs    | OHSAS  | 9 |         |
| performance       | either in their current     | Rep    | / |         |
|                   | form or by incorporation    | with   | 3 |         |
|                   | into the ESRs               | staff  | 0 |         |
|                   |                             |        | / |         |
|                   |                             |        | 0 |         |
|                   |                             |        | 8 |         |
+-------------------+-----------------------------+--------+---+---------+
|                   | Improve JRA awareness by    | OHSAS  | A |         |
|                   | incorporating into Work     | Rep    | t |         |
|                   | Planning (ref in ESRs and   |        | a |         |
|                   | WPs)                        |        | n |         |
|                   |                             |        | n |         |
|                   |                             |        | u |         |
|                   |                             |        | a |         |
|                   |                             |        | l |         |
|                   |                             |        | r |         |
|                   |                             |        | e |         |
|                   |                             |        | v |         |
|                   |                             |        | i |         |
|                   |                             |        | e |         |
|                   |                             |        | w |         |
|                   |                             |        | f |         |
|                   |                             |        | o |         |
|                   |                             |        | r |         |
|                   |                             |        | E |         |
|                   |                             |        | S |         |
|                   |                             |        | R |         |
|                   |                             |        | s |         |
|                   |                             |        | o |         |
|                   |                             |        | r |         |
|                   |                             |        | u |         |
|                   |                             |        | p |         |
|                   |                             |        | o |         |
|                   |                             |        | n |         |
|                   |                             |        | s |         |
|                   |                             |        | u |         |
|                   |                             |        | b |         |
|                   |                             |        | m |         |
|                   |                             |        | i |         |
|                   |                             |        | s |         |
|                   |                             |        | s |         |
|                   |                             |        | i |         |
|                   |                             |        | o |         |
|                   |                             |        | n |         |
|                   |                             |        | o |         |
|                   |                             |        | f |         |
|                   |                             |        | n |         |
|                   |                             |        | e |         |
|                   |                             |        | w |         |
|                   |                             |        | / |         |
|                   |                             |        | r |         |
|                   |                             |        | e |         |
|                   |                             |        | v |         |
|                   |                             |        | i |         |
|                   |                             |        | s |         |
|                   |                             |        | e |         |
|                   |                             |        | d |         |
+-------------------+-----------------------------+--------+---+---------+
|                   | ##                          | ESH    | 4 |         |
|                   | ## Reduce potential for acc | Coord, | ^ |         |
|                   | ident or injury by submitti |        | t |         |
|                   | ng 2 S2 Proposals/successes |        | h |         |
|                   |                             |        | ^ |         |
|                   |                             |        | Q |         |
|                   |                             |        | t |         |
|                   |                             |        | r |         |
|                   |                             |        | ( |         |
|                   |                             |        | s |         |
|                   |                             |        | e |         |
|                   |                             |        | e |         |
|                   |                             |        | S |         |
|                   |                             |        | 2 |         |
|                   |                             |        | S |         |
|                   |                             |        | c |         |
|                   |                             |        | h |         |
|                   |                             |        | e |         |
|                   |                             |        | d |         |
|                   |                             |        | u |         |
|                   |                             |        | l |         |
|                   |                             |        | e |         |
|                   |                             |        | ) |         |
+-------------------+-----------------------------+--------+---+---------+
|                   | #### Conduct a speci        | Ve     | O |         |
|                   | al animal training session  | t/BLAF | n |         |
|                   | for summer students as part | staff  | g |         |
|                   |  of the summer student orie |        | o |         |
|                   | ntation. Also, give hands o |        | i |         |
|                   | n training to staff who are |        | n |         |
|                   |  inexperienced or have been |        | g |         |
|                   |  bitten/scratched by an ani |        |   |         |
|                   | mal during experimentation. |        |   |         |
+-------------------+-----------------------------+--------+---+---------+
|                   | #### Improve glove sel      | ESH    | 1 |         |
|                   | ection for PPE by evaluatin | Coord. | ^ |         |
|                   | g options and providing cho |        | s |         |
|                   | ices to staff (ie for anima |        | t |         |
|                   | l handling, cryogens, etc). |        | ^ |         |
|                   |                             |        | - |         |
|                   |                             |        | 4 |         |
|                   |                             |        | ^ |         |
|                   |                             |        | t |         |
|                   |                             |        | h |         |
|                   |                             |        | ^ |         |
|                   |                             |        | Q |         |
|                   |                             |        | t |         |
|                   |                             |        | r |         |
+-------------------+-----------------------------+--------+---+---------+
| ######### Obje    |                             |        |   |         |
| ctive: Improve Op |                             |        |   |         |
| erational Perform |                             |        |   |         |
| ance (compliance) |                             |        |   |         |
+-------------------+-----------------------------+--------+---+---------+
| Improve Tier 1    | -   Closeout violations     | ESH    |   | > 4^th^ |
| performance       |     within 90 days          | C      |   | > Qtr   |
|                   |                             | oordin |   |         |
|                   | -   Investigate chemical    | ators, |   |         |
|                   |     safety violations and   | ECR,   |   |         |
|                   |     develop corrective      | OSH    |   |         |
|                   |     action plan to address. | Rep    |   |         |
|                   |                             |        |   |         |
|                   | -   Focus on OSHA           |        |   |         |
|                   |     particularly hazardous  |        |   |         |
|                   |     substances              |        |   |         |
+-------------------+-----------------------------+--------+---+---------+
|                   | Improve RCRA compliance by  | EMS    |   | >       |
|                   | meeting with repeat         | R      |   | Ongoing |
|                   | offenders to discuss issues | ep/ECR |   |         |
|                   | and resolutions.            |        |   |         |
+-------------------+-----------------------------+--------+---+---------+
| Improve           | #### Wor                    | EMS    |   | > 4^th^ |
| Environmental     | k to reduce UMC footprint:  | Rep    |   | > Qtr   |
| Performance       |                             | /Bldg. |   |         |
|                   | #### Use ALD funding to re  | Mg     |   |         |
|                   | move excess materials in at | rs/ECR |   |         |
|                   |  least one bin in 490 Basem |        |   |         |
|                   | ent (Priority: Bin B, F, T, |        |   |         |
|                   |  hot waste sampling room, l |        |   |         |
|                   | ead lined room 1^st^ floor) |        |   |         |
|                   |                             |        |   |         |
|                   | #### Dispose o              |        |   |         |
|                   | f excess materials in 463 h |        |   |         |
|                   | angar-high bay and basement |        |   |         |
|                   |  areas (BO Operating funds) |        |   |         |
|                   |                             |        |   |         |
|                   | #### Wor                    |        |   |         |
|                   | k with BES to continue to d |        |   |         |
|                   | ispose of legacy materials  |        |   |         |
|                   | in 901. (as funding allows) |        |   |         |
|                   |                             |        |   |         |
|                   | -   Dispose of              |        |   |         |
|                   |     out-of-service crane in |        |   |         |
|                   |     Bldg. 801               |        |   |         |
+-------------------+-----------------------------+--------+---+---------+
|                   | Apply for an air permit for | Hooda, |   | 2^nd^   |
|                   | BLIP                        | M      |   | Qtr     |
|                   |                             | ausner |   |         |
+-------------------+-----------------------------+--------+---+---------+
|                   | Submit at least 2 Pollution | EMS    |   | 2^nd^   |
|                   | Prevention Proposals (one   | R      |   | Qtr     |
|                   | with a GHG focus). Submit 1 | ep/ECR |   | (see    |
|                   | success story               |        |   | program |
|                   |                             |        |   | call)   |
|                   |                             |        |   |         |
|                   |                             |        |   | 4^th^   |
|                   |                             |        |   | Qtr     |
|                   |                             |        |   | (       |
|                   |                             |        |   | success |
|                   |                             |        |   | story)  |
+-------------------+-----------------------------+--------+---+---------+
|                   | Encourage staff to set      | EMS    |   | 2^nd^   |
|                   | energy saver functions on   | R      |   | Qtr     |
|                   | computers and other         | ep/ITD |   |         |
|                   | electronics by email or     | L      |   |         |
|                   | newsletter.                 | iaison |   |         |
+-------------------+-----------------------------+--------+---+---------+
| #### Im           | #### Implement th           | ESH    |   | 4^th^   |
| prove Electrical  | e Nationally Recognized Tes | Coordi |   | Qtr     |
| Safety Compliance | ting Laboratory (NRTL) Cert | nators |   |         |
|                   | ification program and 5 yea |        |   |         |
|                   | r plan developed in FY 2005 |        |   |         |
|                   |                             |        |   |         |
|                   | #### Continue t             |        |   |         |
|                   | o inventory non-UL listed e |        |   |         |
|                   | quipment---Goal is to compl |        |   |         |
|                   | ete bldg 901(imaging areas) |        |   |         |
+-------------------+-----------------------------+--------+---+---------+
| ###               | Meet with FSS to establish  | FS     |   | 1^st    |
| # Improve Radiolo | more efficient work         | w/PET  |   | ^-4^th^ |
| gical Performance | processes for short lived   | staff  |   | Qtr     |
|                   | isotopes used at 901/906    |        |   |         |
|                   | and improve communication.  |        |   |         |
|                   | Consider a review by an     |        |   |         |
|                   | outside SME.                |        |   |         |
+-------------------+-----------------------------+--------+---+---------+
| Improve           | #### Improve Biological     | SHSD   |   | 3rd Qtr |
| Biological Safety |  Safety by implementing a R | Rep    |   |         |
| Performance       | odent allergen program. Dev | Lead   |   |         |
|                   | elop methodology to conduct |        |   |         |
|                   |  exposure monitoring for an |        |   |         |
|                   | imal allergens (to be incor |        |   |         |
|                   | porated IH Monitoring Progr |        |   |         |
|                   | am) and conduct monitoring. |        |   |         |
+-------------------+-----------------------------+--------+---+---------+
|                   | ####                        | Biol   |   | 2^nd^   |
|                   |  Improve Biological Safety: | ogical |   | Qtr     |
|                   |                             | S      |   |         |
|                   | Revise the Biological       | ME/IBC |   |         |
|                   | Subject Area and            | Reps   |   |         |
|                   | incorporate changes in CDC  |        |   |         |
|                   | Biosafety guidelines.       |        |   |         |
+-------------------+-----------------------------+--------+---+---------+
| Improve OSH       | ####                        | ESH    |   | 9/30/08 |
| Compliance        | Close actions identified ga | Coords |   | (see    |
|                   | p analysis for 851 and subm |        |   | plan    |
|                   | it to SHSD---see Corrective |        |   | when    |
|                   |  Action Plan (Note: Current |        |   | dev     |
|                   | ly under development SHSD)  |        |   | eloped) |
+-------------------+-----------------------------+--------+---+---------+
|                   | #### C                      | Spec'l |   | 2^nd^   |
|                   | ommunicate with DOE to obta | Asst,  |   | Qtr     |
|                   | in 851 SMF variance (alread | SHSD   |   | (con    |
|                   | y submitted) and continue t | Mgr    |   | tingent |
|                   | o provide required reports. |        |   | on DOE  |
|                   |                             |        |   | app'l)  |
+-------------------+-----------------------------+--------+---+---------+
|                   | #### Review revised Documen | EMS    |   | 4^th^   |
|                   | t Control Subject Area agai | and    |   | Qtr     |
|                   | nst current program and upd | OHSAS  |   |         |
|                   | ate documents as necessary. | Rep,   |   | (after  |
|                   |                             | ECRs   |   | pub     |
|                   |                             | and QA |   | lished) |
|                   |                             | Reps   |   |         |
+-------------------+-----------------------------+--------+---+---------+
| ######### Obj     |                             |        |   |         |
| ective: Communica |                             |        |   |         |
| tions Improvement |                             |        |   |         |
+-------------------+-----------------------------+--------+---+---------+
| Improve           | Provide the FY 2007         | ALD,   |   | 2nd Qtr |
| Awareness,        | objectives to the staff for | Chairs |   |         |
| feedback and      | awareness and feedback via  |        |   |         |
| improvement       | newsletter                  |        |   |         |
+-------------------+-----------------------------+--------+---+---------+
|                   | Senior Management Work      | ALD,   |   | Ongoing |
|                   | Observations                | Chairs |   |         |
|                   |                             |        |   |         |
|                   | (ALD 24/yr, Chairs 12/yr,   |        |   |         |
|                   | Level IIIs 2/yr)            |        |   |         |
+-------------------+-----------------------------+--------+---+---------+
|                   | Develop an Ideas Program to | ALD or |   | 4^th^   |
|                   | be piloted in FY08 and      | de     |   | Qtr     |
|                   | rolled out in FY09          | signee |   |         |
|                   |                             | (I     |   |         |
|                   |                             | nstitu |   |         |
|                   |                             | tional |   |         |
|                   |                             | comm   |   |         |
|                   |                             | ittee) |   |         |
+-------------------+-----------------------------+--------+---+---------+
|                   | Participate on              | ALD,   |   | See BNL |
|                   | Institutional committee to  | de     |   | POC     |
|                   | develop and implement Human | signee |   |         |
|                   | Performance                 |        |   |         |
+-------------------+-----------------------------+--------+---+---------+