University of Idaho

Blood Borne Pathogens Policy

(Part 3)

VIII.    Record Keeping (29 CFR 1910.1030 (h)

   IX.    Appendices

               A. Definitions
               B. Regulatory Authority
               C. Job Descriptions
               D. Biohazard Label
               E. Cleaning Guidelines
               F. Vaccination Request Form
               G. Vaccination Declination Form
               H. Post Exposure Investigation Checklist
                    Post Exposure Incident Form
                    Post Exposure Physicians Evaluation
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VIII Record Keeping (29 CFR 1910.1030 (h)]

Medical and training records shall be made available to the Assistant Secretary of the Occupational Health and Safety Administration or the Director of National Institute for Occupational Safety and Health as required by 29 CFR 1910.20. Records shall also be made available to the subject employee and to anyone with the written permission of the subject employee.

A. Medical records

Confidential medical records shall be kept at Student Health Center for 30 years past the last date of employment. Like all medical records, these records shall not be disclosed without the expressed written consent of the employee, except as required by law.

The medical records shall contain:

1. Employee's name and social security number.

2. Documentation of employee's HBV vaccination or a declination form signed by the employee (Appendix G).

3. In case of occupational exposure, copies of the post exposure forms (Appendix H).

B. Training records

Training records shall be maintained for at least three years after the last date of employment.

Records shall include:

1. Date of training class.

2. Names, job titles and signature of attendees.

3. Course outline.

4. Names and qualifications of persons conducting the course.

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Appendix A
Definitions


Assistant Secretary Means the Assistant Secretary of Labor of Occupational Safety and Health, or designated representative.

Autoclave To sterilize with a combination of pressure and heat.

Blood Means human blood, human blood components, and products made from human blood.

Blood Borne Pathogens Means pathogenic microorganisms that are present in human blood and can cause disease in humans. These pathogens include, but are not limited to, hepatitis B virus (HBV) and human immunodeficiency virus (HIV).

Clinical Laboratory Means a workplace where diagnostic or other screening procedures are performed on blood or other potentially infectious materials.

Contaminated Means the presence or the reasonably anticipated presence of blood or other potentially infectious materials on an item or surface.

Contaminated Laundry Means laundry which has been soiled with blood or other potentially infectious materials or may contain contaminated sharps.

Contaminated Sharps Means any contaminated object that can penetrate the skin including, but not limited to, needles, scalpels, broken glass, broken capillary tubes, and exposed ends of dental wires.

Decontamination Means the use of physical or chemical means to remove, inactivate, or destroy blood borne pathogens on a surface or item to the point where they are no longer capable of transmitting infectious particles and the surface or item is rendered safe for handling, use, or disposal.

Director Means the Director of the National Institute for Occupational Safety and Health, U.S. Department of Health and Human Services, or designated representative.

Engineering Controls Means controls (e.g., contaminated sharps disposal containers, self-sheathing needles) that isolate or remove the blood borne pathogens hazard from the workplace.

Exposure Incident Means a specific eye, mouth, other mucous membrane, non-intact skin, or parenteral contact with blood or other potentially infectious materials that results from the performance of an employee's duties.

Facility Is the University of Idaho main campus, branch campuses, research stations or extension offices.

Handwashing Facilities Means a facility providing an adequate supply of running potable water, soap and single use towels or hot air drying machines.

Licensed Healthcare Is a person whose legally permitted scope of practice allows him

Professional or her to independently perform the activities required by Section VI "HBV Vaccinations and Post-exposure Counseling"

HBV Means hepatitis B virus.

HIV Means human immunodeficiency virus.

Occupational Exposure Means reasonably anticipated skin, eye, mucous membrane, or parenteral contact with blood or other potentially infectious materials that may result from the performance of an employee's duties.

Other Potentially Means (1) The following human body fluids: semen, vaginal Infectious Materials secretions, cerebrospinal fluid, synovial fluid, pleural fluid, pericardial fluid, peritoneal fluid, amniotic fluid, saliva in dental procedures, any body fluid that is visibly contaminated with blood, and all body fluids in situations where it is difficult or impossible to differentiate between body fluids; (2) Any unfixed tissue or organ (other than intact skin) from a human (living or dead); and (3) HIV-containing cell or tissue cultures, organ cultures, and HIV- or HBV-containing culture medium or other solutions, and blood, organs, or other tissues from experimental animals infected with HIV or HBV.

Parenteral Means piercing mucous membranes or the skin barrier through such events as needle sticks, human bites, cuts, and abrasions.

Personal Protective Is specialized clothing or equipment worn by an employee for

Equipment protection against a hazard. General work clothes (e.g. uniforms, pants, shirts or blouses) not intended to function as protection against a hazard are not considered to be personal protective equipment.

Phlebotomy To obtain a blood or serum sample by venipuncture.

Production Facility Means a facility engaged in industrial-scale, large-volume or high concentration production of HIV or HBV.

Regulated Waste Means liquid or semi-liquid blood or other potentially infectious materials; contaminated items that would release blood or other potentially infectious materials in a liquid or semi-liquid state; items that are caked with dried blood or other potentially infectious materials and are capable of releasing these materials during handling; contaminated sharps; and pathological and microbiological wastes containing blood or other potentially infectious materials.

Research Laboratory Means a laboratory producing or using research-laboratory-scale amounts of HIV or HBV. Research laboratories may produce high concentrations of HIV or HBV but not in the volume found in production facilities.

Sharps Means any object that can penetrate the skin including, but not limited to, needles, scapel, broken glass, broken capillary tubes, and exposed ends of dental wires.

Source Individual Means any individual, living or dead, whose blood or other potentially infectious materials may be a source of occupational exposure to the employee. Examples include, but are not limited to, hospital and clinic patients; clients in institutions for the developmentally disabled; trauma victims; clients of drug and alcohol treatment facilities; residents of hospices and nursing homes; human remains; and individuals who donate or sell blood or blood components.

Sterilize Means the use of a physical or chemical procedure to destroy all microbial life including highly resistant bacterial endospores.

Universal Precautions Is an approach to infection control. According to the concept of Universal Precautions, all human blood and certain human body fluids are treated as if known to be infectious for HIV, HBV, and other blood borne pathogens.

Work Practice Controls Means controls that reduce the likelihood of exposure by altering the manner in which a task is performed (e.g., prohibiting recapping of needles by a two-handed technique).

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Appendix B
Regulatory Authority

Reserved

 
Blood Borne Pathogen Policy 
Appendix C
Job Descriptions


1. Job classifications where all University employees have occupational exposure to human blood or     other potentially infectious materials.

07609 Nurse Registered

07610 Nurse Aide

12404 Student Health Director

12415 University Physician

17463 Nurse Practitioner

17674 Medical Assistant
 
 

2. Job classifications in which some University employees have occupational exposure to human blood or other potentially infectious materials.

02010 Custodian-all classifications

11220 Postdoctoral Fellow

11230 Research Associate

11357 Research Scientist

11359 Research Fellow

11500 Research Assistant

12042 Child Care Center, Director; Child Care Center Assistant

12500 Football Coach, Head

12501 Basketball Coach, Head

12505 Track Cross Country Coach

12509 Assistant Football Coach

12510 Assistant Basketball Coach

12511 Athletic Trainer

12518 Volleyball Coach

12520 Women's Basketball Coach

12521 Track Field Coach, Women

12530 Assistant Women's Basketball Coach

12531 Assistant Volleyball Coach

13102 Scientific Aide I

13103 Research Technician Aide I

13104 Research Technician Aide II

13105 Research Technician Aide III

13198 Scientific Aide II

13509 Athletic Equipment Manager

15453 Research Technician I

15454 Research Technician II
 
 

2. Job classifications in which some University employees have occupational exposure to human blood or other potentially infectious materials (cont).

17616 Research Technician III

17669 Research Support Scientist I

17670 Research Support Scientist II

17671 Research Support Scientist III

17675 Scientific Aide III

17679 Patrol Person

18182 Child Development Lab Manager

Life Guards

Swim Instructors

Diving Instructors
 
 

3. Tasks and procedures performed by University personnel where occupational exposure to human blood or other potentially infectious materials may be reasonably expected to occur.

a. Medical or research personnel may be exposed during procedures such as suturing, phlebotomy, pregnancy testing, wound cleaning, wound dressing, pelvic examinations, obtaining and/or culturing laboratory specimens, and any other medical or research procedure that is likely to involve contact with human blood or other potentially infectious material.

b. Athletic program staff may be exposed during contact with injured athletes and while cleaning whirlpools or other equipment.

c. Child care staff may be exposed to human blood or other potentially infectious materials during contact with injured or ill children.

d. Security personnel may be exposed to human blood or other potentially infectious materials when responding to an emergency.

e. Custodial staff may be exposed to blood or other potentially infectious materials through the course of routine cleaning. Examples would include cleaning areas visibly contaminated with blood-stained vomit, feces or urine, or discarding potentially contaminated trash, such as used feminine hygiene products.

f. Swim Center staff may be exposed to blood and other potentially infectious materials during resuscitation and other first aid procedures.

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Appendix D
Biohazard Label



 
 
 
 
BIOHAZARD
 

 
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Appendix E
Cleaning Guidelines


1. Gloves shall be worn when cleaning potentially contaminated materials.

2. Potentially infectious waste shall be decontaminated prior to clean up. An approved decontaminating agent is 1:10 solution of chlorine bleach (eg, 1 part Clorox® diluted with 9 parts of water).

3. Large spills of contaminated liquid shall be adsorbed with sorbent powder prior to clean up.

4. Contaminated sharps shall be picked up with a dust pan and broom or with tongs. Personnel shall not touch contaminated sharps with their hands.

5. Sanitary napkin disposal containers shall be assumed to be contaminated. Gloves shall be worn while removing the disposal bag. Disposal bag shall be discarded as biohazardous waste and shall be autoclaved or incinerated prior to leaving the facility. Any visible contamination shall be cleaned with a 1:10 chlorine bleach solution or other equally effective germicidal solution.

6. When disassembling or repairing potentially contaminated equipment or objects, gloves should be worn and a means of preventing further contamination should be in place. This may include a bucket to catch fluid, adsorbent to solidify liquids, germicide disinfectant to decontaminate materials, etc. Contaminated equipment may include centrifuges, pipettors, incubators, plumbing drains, etc.

7. Re-usable first aid equipment such as suture needles, forceps, one-way CPR masks, etc shall be disinfected with an appropriate germicide disinfectant after exposure to human blood or other potentially infectious materials.

8. Diluted chlorine bleach solutions are effective for a limited length of time and should be freshly made once a week. Other germicidal solutions may retain their effectiveness for longer periods of time; consult manufacturer's recommendations for more information.

9. Personnel who may encounter possible infectious materials frequently are encouraged to make a response kit. Supplies could be stored in a bucket and the bucket used to decontaminate any re-usable equipment. Specific requirements for a response kit may vary depending upon the type of contamination most frequently encountered. Below are basic recommendations for a general purpose response kit.
For information on the handling and disposal of feminine hygiene products, refer to Femine Hygiene Products Page.

Recommended supplies for an infectious materials response kit are:

Item                                                                                      Example
 

Disposable latex gloves  
Disposable rags, cloths or sponges
Dust pan 
Whisk broom with plastic bristles
Tongs to pick up broken glass and other contaminated sharps
Sorbent to convert liquid to solid waste  Isolyser liquid treatment system 

"Scoopable" cat litter

Germicidal cleaner  Wipe Out disinfectant 

1:10 chlorine bleach solution

Handwashing towelettes Vionex medicated soap 
Labelled disposal bags Autoclave bags preprinted with biohazard label
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Appendix F
Vaccination Request Form


Directions: The following employee, because of his/her job requirements, is at risk of exposure to Hepatitis B virus (HBV). In compliance with the University of Idaho Blood Borne Pathogen Policy a HBV vaccination series is being offered to the employee at departmental expense. Please date, initial, fill-in the call back date and forward a copy of this form to Environmental Health and Safety for each vaccination in the series. Environmental Health and Safety will notify the employee when the next vaccination is due.
 

Employee's Name: _____________________________________

Job Title: ____________________________________________

Department: __________________________________________
 
 
 

HBV Vaccination Date Doctor's Initials Call Back Due Call Back Date
Series 1      1 month after series 1  
Series 2      6 months after series 1  
Series 3        
Booster         
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Appendix G
Vaccination Declination Form


Employee Name: __________________________________           Date: ___________

                                                                 Please print or type
 

I understand that due to my occupational exposure to blood or other potentially infectious materials I may be at risk of acquiring Hepatitis B virus (HBV) infection. I have been given the opportunity to be vaccinated with Hepatitis B vaccine, at no charge to myself. However, I decline the Hepatitis B vaccine at this time. I understand that by declining this vaccine, I continue to be at risk of acquiring Hepatitis B, a serious disease. If, in the future, I continue to have occupational exposure to blood or other potentially infectious materials and I want to be vaccinated with the Hepatitis B vaccine, I can receive the vaccine series at no charge to me.
 

Employee's Signature: _______________________         Date:__________

Physician's Signature:  _______________________         Date:__________
 

 
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  Appendix H
Post Exposure Investigation Checklist


Employee's name: ____________________________      Incident date: ___________

Job title: ____________________________________
 
 
 

Activity Responsibility Date Initials
Incident form completed Industrial Hygienist 

Env Health & Safety

   
Source individual identified 

Name: _____________________

Director 

Student Health

   
Consent for testing source's blood obtained 

Unable to obtain consent ___________

Director 

Student Health

   
HIV and HBV serological testing 

on employee's blood

Director 

Student Health

   
Appointment for employee with physician Director 

Student Health

   
Complete worker compensation forms Occupational Safety Specialist 

Env Health & Safety

   
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Appendix H
Post Exposure Incident Form


Directions: The University Industrial Hygienist and exposed employee shall complete this form within five days of a possible exposure incident. A copy shall be given to the Student Health Center and Environmental Health and Safety.

Employee's name: ____________________________________

Job title: ____________________________________________

Date of incident: ___________________        Time of incident: _______________________

Location of incident: _________________________________________________________

Potentially infectious material involved: ____________________________________

Source of material: _____________________________________________________

Work performed during incident: __________________________________________

How incident occurred: __________________________________________________

Protective equipment used: _______________________________________________

Decontamination: _______________________________________________________

Clean-up: ______________________________________________________________

Reported to: ____________________________________________________________

Referred to physician: ____________________________________________________

Comments: _____________________________________________________________

_______________________________________________________________________

Recommendations: _______________________________________________________

________________________________________________________________________

Industrial Hygienist's signature: ______________________________     Date:______
 

 
 
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Appendix H
Post Exposure Physician Evaluation


Directions: The physician shall complete this form within 15 days of examining exposed employee demonstrating that s/he has discussed the following with the exposed employee.

Employee's Name: __________________________________     Date: ___________

1. Hepatitis B vaccination is recommended?       Yes  ______          No_______

2. Employee received Hepatitis B vaccination?   Yes  ______          No _______

If yes, date received: ______________________

3. Informed of the results of the exam?                 Yes ____      No______

4. Given results of source's serological testing?     Yes_____     No ______

5. Possible medical conditions resulting from exposure

have been explained to employee?                        Yes_____    No______

6. Laws and regulations governing disclosure of source's

identity and serological status?                              Yes_____    No______

7. Available prophylactic treatment discussed?      Yes_____    No______

8. Available counseling discussed?                        Yes_____    No______

 
****************************************************************************

December 16, 1997
 

MEMORANDUM

TO: University Employee

FROM: Robyn Herring, Industrial Hygienist, Environmental Health and Safety

RE: Hepatitis B Vaccination
 
 

Due to the nature of your position, you may be at risk of being exposed to human blood or other potentially infectious materials, and as such, the hepatitis B virus. At the recent training course you attended, procedures for reducing exposure risk, using personal protective equipment, and decontaminating potentially infectious materials were discussed.

As also covered in the training course, you are allowed to receive a hepatitis B vaccination series at departmental expense. This is a reminder that you need series needed by date . Vaccinations may be scheduled at Student Health Center (885-6693).
 

Thank you.
 

enclosure
 

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