UW CollegesBloodborne Pathogens Exposure Control Plan

February 27, 2015

POLICY

The UW Colleges are committed to providing a safe andhealthful work environment for our entire staff. In pursuit of thisgoal, the following exposure control plan (ECP) is providedto eliminate or minimize occupational exposure to bloodbornepathogens in accordance with OSHA standard 29 CFR 1910.1030,“Occupational Exposure to Bloodborne Pathogens.”

The ECP is a key document to assist our organization inimplementing and ensuring compliance with the standard, therebyprotecting our employees. This ECP includes:

■ Determination of employee exposure■ Implementation of various methods of exposure control,including:Universal precautionsEngineering and work practice controlsPersonal protective equipmentHousekeeping■ Hepatitis B vaccination■ Post-exposure evaluation and follow-up■ Communication of hazards to employees and training■ Recordkeeping■ Procedures for evaluating circumstances surrounding exposureIncidents

Implementation methods for these elements of the standard arediscussed in the subsequent pages of this ECP.

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PROGRAM ADMINISTRATION ■ The Campus Assistant Dean for Administration and Finance (ACDAF) is responsible for implementation of the ECP. The ACDAF and the UW Colleges Risk Manager will maintain, review, and update the ECP at least annually, and whenever necessary to include new or modified tasksand procedures. Contact location/phone number: UW Colleges Risk Manager @ 608-265-0621 ■ Those employees who are determined to have occupationalexposure to blood or other potentially infectious materials (OPIM)must comply with the procedures and work practices outlined inthis ECP.■ The Building and Grounds Superintendent will provide andmaintain all necessary personal protective equipment (PPE),engineering controls (e.g., sharps containers), labels, and red bagsas required by the standard. The Building and Grounds Superintendent will ensure that adequate supplies of the aforementioned equipment are available in the appropriate sizes. Contact location/phone number: Building and Grounds Superintendent respective phone number _________________________ .■ The ACDAF will be responsible for ensuring that all medical actions required by the standard are performed and that appropriate employee health and OSHA records are maintained. Contact location/phonenumber: ACDAF’s respective phone number_______________________■ UW Colleges Risk Manager will be responsible for training, documentation of training, and making the written ECPavailable to employees, OSHA, and NIOSH representatives.Contact location/phone number: Madison Office 608-265-0621.

EMPLOYEE EXPOSURE DETERMINATION

The following is a list of the primary job classifications at our establishment

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in which all employees have occupational exposure, others may be added to meet a campuses needs: Job Title Department/LocationBuilding and Grounds Superintendent Maintenance Custodian MaintenanceFacility Repair Worker MaintenanceCustodial Supervisor MaintenanceHVAC Specialist MaintenanceLaborer MaintenanceAthletic Director AthleticsCoaches AthleticsLab Technicians AcademicsLab Professors Academics

The following is a list of the primary job classifications in which someemployees at our establishment have occupational exposure, others may be added to meet a campuses needs. Included is a list of tasks and procedures, or groups of closely related tasks and procedures, in which occupational exposure may occur for these individuals:

Job Title Department/Location Task/ProcedureBuilding and Grounds Superintendent Maintenance Custodian MaintenanceFacility Repair Worker MaintenanceCustodial Supervisor MaintenanceHVAC Specialist MaintenanceLaborer MaintenanceAthletic Director AthleticsCoaches AthleticsLab Technicians AcademicsLab Professors Academics

All have the potential for body fluid clean up and handling regulated waste.

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METHODS OF IMPLEMENTATION AND CONTROL

Universal PrecautionsAll employees will utilize universal precautions.

Exposure Control PlanEmployees covered by the bloodborne pathogens standardreceive an explanation of this ECP during their initial trainingsession. It will also be reviewed in their annual refresher training.All employees can review this plan at any time during their workshifts by contacting Building and Grounds Superintendent. Ifrequested, we will provide an employee with a copy of the ECPfree of charge and within 15 days of the request. UW Colleges Risk Manager is responsible for reviewing and updating the ECP annually or more frequently if necessary to reflect any new or modified tasks and procedures that affect occupational exposure and to reflect new or revisedemployee positions with occupational exposure.

Engineering Controls and Work PracticesEngineering controls and work practice controls will be used toprevent or minimize exposure to bloodborne pathogens. The specific engineering controls and work practice controls used are listed below:

■ _Sharps disposal containers■ _Lab trays designated for sharps__

Sharps disposal containers are inspected and maintained orreplaced by the Custodial Department daily to prevent overfilling.

This institution identifies the need for changes in engineeringcontrols and work practices through review of OSHArecords, employee interviews, committee activities, etc.

We evaluate new procedures and new products regularly by literature review, supplier information, and best practices from other sites or industries.

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Both front-line workers and management officials are involvedin this process in the following manner: Campus Safety Committee review.

The Building and Grounds Superintendent is responsible forensuring that these recommendations are implemented.

Personal Protective Equipment (PPE)PPE is provided to our employees at no cost to them. Training inthe use of the appropriate PPE for specific tasks or procedures isprovided by the Buildings and Grounds Superintendent. This training will be at least annually and upon hire of new staff. Note: State contract online training can also be used.

The types of PPE available to employees are as follows:Gloves, Eye protection, Spill Kits, Gowns and Face protection as needed.

PPE is located in the Maintenance Office and may be obtained throughcontacting the Building and Grounds Superintendent or Custodial staff. PPE supplies will be monitored and re ordered as needed by the Building and Grounds Superintendent. All employees using PPE must observe the following precautions:

■ Wash hands immediately or as soon as feasible after removinggloves or other PPE.■ Remove PPE after it becomes contaminated and before leavingthe work area.■ Used PPE may be disposed of in a proper impervious bag and taken to the Building and Grounds office for disposal. ■ Wear appropriate gloves when it is reasonably anticipated thatthere may be hand contact with blood or OPIM, and when handlingor touching contaminated items or surfaces; replace gloves if torn,punctured or contaminated, or if their ability to function as a barrier

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is compromised.■ Utility gloves may be decontaminated for reuse if their integrityis not compromised; discard utility gloves if they show signs ofcracking, peeling, tearing, puncturing, or deterioration.■ Never wash or decontaminate disposable gloves for reuse.■ Wear appropriate face and eye protection when splashes,sprays, spatters, or droplets of blood or OPIM pose a hazard to theeye, nose, or mouth.■ Remove immediately or as soon as feasible any garment contaminatedby blood or OPIM, in such a way as to avoid contact with the outer surface.

HousekeepingRegulated waste is placed in containers which are closable,constructed to contain all contents and prevent leakage, appropriatelylabeled or color-coded (see the following section “Labels”),and closed prior to removal to prevent spillage or protrusion ofcontents during handling.

The procedure for handling sharps disposal containers is:

Remove container and tape all openings, replace with a new container, take full container to the Building and Grounds Superintendent for proper disposal. The procedure for handling other regulated waste is:

Ensure that all waste is in an impervious bag and take the waste the Building and Grounds Superintendent for proper disposal.

Contaminated sharps are discarded immediately or as soon aspossible in containers that are closable, puncture-resistant, leakproof on sides and bottoms, and appropriately labeled or color-coded.

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Sharps disposal containers are available at the Building and Grounds Superintendent office.

Bins and pails (e.g., wash or emesis basins) are cleaned anddecontaminated as soon as feasible after visible contamination.

Broken glassware that may be contaminated is only picked upusing mechanical means, such as a brush and dustpan.

LaundryThe following laundering requirements must be met:■ handle contaminated laundry as little as possible, with minimalagitation■ place wet contaminated laundry in leak-proof, labeled or color-codedcontainers before transport. Use red bags for this purpose.■ wear the following PPE when handling and/or sorting contaminatedlaundry: Gloves and gown as needed.

LabelsThe following labeling methods are used in this institution:Use of red bags for all waste or contaminated items.

The Building and Grounds Superintendent is responsible forensuring that warning labels are affixed or red bags are used asrequired if regulated waste or contaminated equipment is broughtinto the institution. Employees are to notify the Building and Grounds Superintendent if they discover regulated waste containers,refrigerators containing blood or OPIM, contaminated equipment,etc., without proper labels.

HEPATITIS B VACCINATION (Flowchart Attachment F)

*NOTE – All confidential documents will be maintained in a file such as a Sharepoint or other electronic method.

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ACDAF in conjunction with supervisor will ensure training is provided to pre-determined employees (page 2) on hepatitis B vaccinations, addressing safety, benefits, efficacy, methods of administration, and availability.

The hepatitis B vaccination series is available at no cost afterinitial employee training and within 10 days of initial assignment toall employees identified in the exposure determination section ofthis plan. Vaccination is encouraged unless: 1) documentation existsthat the employee has previously received the series; 2) antibodytesting reveals that the employee is immune; or 3) medicalevaluation shows that vaccination is contraindicated.

However, if an employee declines the vaccination, the employee must sign a declination form (Attachment A). Employees who decline mayrequest and obtain the vaccination at a later date at no cost.Documentation of refusal of the vaccination is kept on file by ACDAF.

Vaccination will be provided by the employees physician or by a location specified by ACDAF (List health care professional responsible for this part of the plan) at (location). A tracking form of vaccine doses is provided if the institution chooses, not required (Attachment B).

Following the medical evaluation, a copy of the health care professional’swritten opinion (Attachment C) will be obtained and provided to the employee within 15 days of the completion of the evaluation. It will be limited to whether the employee requires the hepatitis vaccine and whether the vaccine was administered. A copy of this evaluation must be provided to the ACDAF and kept on file. The ACDAF will send a copy of the written opinion to Central Office Human Resources Department.

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POST-EXPOSURE EVALUATION AND FOLLOW-UP (Flowchart Attachment G)

Should an exposure incident occur, contact the ACDAF at the following number __(respective ACDAF’s phone number) .

Following initial first aid (clean the wound, flush eyes or other mucous membrane, etc.), the following activities will be performed:

An immediately available confidential medical evaluation andfollow-up will be conducted by the employees physician or at clinic recommended by ACDAF (name of licensed health care professional). Form letter to provide to the Physician is attached (Attachment D).

Items included in the form letter:■ Document the routes of exposure and how the exposureoccurred.■ Identify and document the source individual (unless theemployer can establish that identification is infeasible or prohibitedby state or local law).■ Obtain consent and make arrangements to have the sourceindividual tested as soon as possible to determine HIV, HCV, andHBV infectivity; document that the source individual’s test resultswere conveyed to the employee’s health care provider.■ If the source individual is already known to be HIV, HCV and/orHBV positive, new testing need not be performed.■ Assure that the exposed employee is provided with the sourceindividual’s test results and with information about applicabledisclosure laws and regulations concerning the identity andinfectious status of the source individual (e.g., laws protecting confidentiality).■ After obtaining consent, collect exposed employee’s blood assoon as feasible after exposure incident, and test blood for HBV andHIV serological status

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■ If the employee does not give consent for HIV serological testingduring collection of blood for baseline testing, preserve the baselineblood sample for at least 90 days; if the exposed employee elects tohave the baseline sample tested during this waiting period, performtesting as soon as feasible.

ADMINISTRATION OF POST-EXPOSUREEVALUATION AND FOLLOW-UP

ACDAF will have the employee or assist the employee with completing an Employee Work Injury and Illness Report, form UWS/OSLP-1Emp (attached).

ACDAF ensures that health care professional(s) responsible for employee’s hepatitis B vaccination and post-exposure evaluation and follow-up are given a copy of OSHA’s bloodborne pathogens standard.

ACDAF ensures that the health care professional evaluating an employee after an exposure incident receives the following:■ a description of the employee’s job duties relevant to theexposure incident■ route(s) of exposure■ circumstances of exposure■ if possible, results of the source individual’s blood test■ relevant employee medical records, including vaccination status

Personal physician provides the employee with a copy of the evaluating health care professional’s written opinion within 15 days after completion of the evaluation (Attachment E). A copy of the written opinion will be provided to the Central Office Human Resources, Workers Compensation Coordinator.

PROCEDURES FOR EVALUATING THE CIRCUMSTANCES

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SURROUNDING AN EXPOSURE INCIDENT

ACDAF will complete the Employer’s First Report of Injury or Disease form (attached).

The employee Supervisor or ACDAF will complete the Supervisor’s Accident Analysis and Prevention Report (attached).

ACDAF will review the circumstancesof all exposure incidents to determine:■ engineering controls in use at the time■ work practices followed■ a description of the device being used (including type andbrand)■ protective equipment or clothing that was used at the time ofthe exposure incident (gloves, eye shields, etc.)■ location of the incident (O.R., E.R., patient room, etc.)■ procedure being performed when the incident occurred■ employee’s training

UW Systems Workers Compensation Coordinator will record all percutaneous injuries from contaminated sharps in a Sharps Injury Log.

If revisions to this ECP are necessary the ACDAF and UW Colleges Risk Manager will ensure that appropriate changes are made.(Changes may include an evaluation of safer devices, addingemployees to the exposure determination list, etc.)

EMPLOYEE TRAINING

All employees who have occupational exposure to bloodbornepathogens receive initial and annual training conducted byUW Colleges Risk Manager, Buildings and Grounds Superintendent or via the State online training program.

All employees who have occupational exposure to bloodbornepathogens receive training on the epidemiology, symptoms, andtransmission of bloodborne pathogen diseases. In addition, the

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training program covers, at a minimum, the following elements:■ a copy and explanation of the OSHA bloodborne pathogenstandard■ an explanation of our ECP and how to obtain a copy■ an explanation of methods to recognize tasks and other activitiesthat may involve exposure to blood and OPIM, including whatconstitutes an exposure incident■ an explanation of the use and limitations of engineeringcontrols, work practices, and PPE■ an explanation of the types, uses, location, removal, handling,decontamination, and disposal of PPE■ an explanation of the basis for PPE selection■ information on the hepatitis B vaccine, including information onits efficacy, safety, method of administration, the benefits of beingvaccinated, and that the vaccine will be offered free of charge■ information on the appropriate actions to take and persons tocontact in an emergency involving blood or OPIM■ an explanation of the procedure to follow if an exposure incidentoccurs, including the method of reporting the incident and themedical follow-up that will be made available■ information on the post-exposure evaluation and follow-up thatthe employer is required to provide for the employee following anexposure incident ■ an explanation of the signs and labels and/or color codingrequired by the standard and used at this institution■ an opportunity for interactive questions and answers with theperson conducting the training session.Training materials for this institution are available at UW Colleges Risk Management office and via the state online training program.

RECORDKEEPING

Training RecordsTraining records are completed for each employee uponcompletion of training. These documents will be kept for at least

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three years at UW Colleges Risk Manager office, onsite at the Campus and Central Office Human Resources.

The training records include:■ the dates of the training sessions■ the contents or a summary of the training sessions■ the names and qualifications of persons conducting the training■ the names and job titles of all persons attending the trainingSessions

Employee training records are provided upon request to theemployee or the employee’s authorized representative within15 working days. Such requests should be addressed toACDAF and/or UW Colleges Risk Manager

Medical RecordsMedical records are maintained for each employee with occupationalexposure in accordance with 29 CFR 1910.1020, “Access toEmployee Exposure and Medical Records.”

The Workers Compensation Coordinator is responsible for forwarding anymedical records in relation to the exposure case to Human Resources and subsequently UW System Workers’ Compensation Office. These confidential records are kept in (DOA Worker Comp Records) for at least the duration of employment plus 30 years.

Employee medical records are provided upon request of theemployee or to anyone having written consent of the employeewithin 15 working days. Such requests should be sent to theACDAF

OSHA RecordkeepingAn exposure incident is evaluated to determine if the case meetsOSHA’s Recordkeeping Requirements (29 CFR 1904). This determinationand the recording activities are done by UW Colleges Human Resources and the UW System Office of Workers’ Compensation

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Sharps Injury LogIn addition to the 1904 Recordkeeping Requirements, all percutaneousinjuries from contaminated sharps are also recorded in aSharps Injury Log. All incidences must include at least:■ date of the injury■ type and brand of the device involved (syringe, suture needle)■ department or work area where the incident occurred■ explanation of how the incident occurred.This log is reviewed as part of the annual program evaluationand maintained for at least five years following the end of thecalendar year covered. If a copy is requested by anyone, it musthave any personal identifiers removed from the report.

Attachment A

HEPATITIS B VACCINE DECLINATION (MANDATORY)

I understand that due to my occupational exposure to blood orother potentially infectious materials I may be at risk of acquiringhepatitis B virus (HBV) infection. I have been given the opportunityto be vaccinated with hepatitis B vaccine, at no charge to myself.However, I decline hepatitis B vaccination at this time. I understandthat by declining this vaccine, I continue to be at risk of acquiringhepatitis B, a serious disease. If in the future I continue to haveoccupational exposure to blood or other potentially infectiousmaterials and I want to be vaccinated with hepatitis B vaccine, I canreceive the vaccination series at no charge to me.

Employee Name Printed __________________________________

Employee Signature: _____________________________________

Date Signed: ______________________

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Attachment B

HEPATITIS B VACCINE RECORD

I understand that due to my occupational exposure to blood orother potentially infectious materials I may be at risk of acquiringhepatitis B virus (HBV) infection. I have been given the opportunityto be vaccinated with hepatitis B vaccine, at no charge to myself. I have elected to receive this vaccination and inform my employerduring the three stages of the vaccination. The vaccination will becompleted over a 4 – 6 month period as prescribed by the Center for Disease Control (CDC).

Employee Name Printed __________________________________

Employee Signature: _____________________________________

Date Signed: ______________________

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Attachment C

Health Care Professionals Written Opinion ForAdministering Hepatitis Vaccine

Health Care Professionals

1. Employee Name:_____________________________________________ 2. Date of Office Visit:__________________________________________ 3. Health Care Facility Address:__________________________________ 4. Health Care Facility Telephone:________________________________

As required under the Bloodborne Pathogen Standard:

______ Hepatitis B vaccination is ____ is not ____ indicated.

______ Hepatitis B vaccination was ____ was not_____ administered.

Signature of health care provider:_______________________ Date: ________

Printed or typed name of health care provider:___________________________

This form is to be returned to the employer, and a copy provided to the employee within 15 days.

Employer Name:______________________________

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Attachment D

INFORMATION PROVIDED TO THE HEALTHCARE PROFESSIONALEVALUATING AN EMPLOYEE AFTER AN EXPOSURE INCIDENT FORM

Dear Healthcare Professional:

One/Some of our employees may have been exposed to bloodborne pathogens during the performance of their work duties. This individual had direct contact with potentially infected blood or other potentially infectious materials.

In accordance with the requirements of OSHA's Bloodborne Pathogen Standard, the exposed employee must immediately have made available to them a confidential medical evaluation and follow-up which must include at least the following elements:

a. Documentation of the route(s) of exposure, and the circumstances under which the exposure incident occurred;b. Identification and documentation of the source individual, unless the UW Colleges can establish that identification is infeasible or prohibited by state or local law;

1) The source individual's blood shall be tested as soon as feasible and after consent is obtained in order to determine HBV and HIV infectivity. If consent is not obtained, the UW Colleges shall establish that legally required consent cannot be obtained. When law does not require the source individual’s consent, the source individual's blood, if available, shall be tested and the results documented.2) When the source individual is already known to be infected with HBV or HIV, testing for the source individual's HBV or HIV status need not be repeated.3) Results of the source individual's testing shall be made available to the exposed employee, and the employee shall be informed of applicable laws and regulations concerning disclosure of the identity and infectious status of the source individual.

c. Collection and testing of blood for HBV and HIV serological status;1) The exposed employee's blood shall be collected as soon as feasible and tested after consent is obtained.2) If the employee consents to baseline blood collection, but does not give consent at that time for HIV serologic testing, the sample shall be preserved for at least 90 days. If, within 90 days of the exposure incident, the employee elects to have the baseline sample tested, such testing shall be done as soon as feasible.

d. d) Post-exposure prophylaxis, when medically indicated, as recommended by theU.S. Public Health Service;e. Counseling; andf. Evaluation of reported illnesses.-Page 1 of 2-

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INFORMATION PROVIDED TO THE HEALTHCARE PROFESSIONALEVALUATING AN EMPLOYEE AFTER AN EXPOSURE INCIDENT FORM

In accordance with the requirements of OSHA's Bloodborne Pathogen Standard, you are being provided with the following information:

a. A copy of the Bloodborne Pathogen Standard (Please pay special attention to sections 1910.1031 (f)(3 to 5) of the Bloodborne Pathogen Standard if you are not familiar with this regulation; the indicated sections deal specifically with post-exposure evaluation and followup, information provided to the healthcare professional, and the healthcare professional's written opinion.);b. A description of the exposed employee's duties as they relate to the exposure incident);c. Documentation of the route(s) of exposure and circumstances under which exposure occurredd. Results of the source individual's blood testing, if available; ande. Copies of all medical records relevant to the appropriate treatment of the employee, including hepatitis B virus vaccination status, which are the UW Colleges responsibility to maintain.

Please review the provided information and complete the post-exposure evaluation form. Return the original copy of the completed form to the UW Colleges and give a copy to the patient within 15 days of the completion of the evaluation.

The healthcare professional's written opinion for post-exposure evaluation and follow-up (copies attached) must be limited to the following information:

a. That the employee has been informed of the results of the evaluation; andb. That the employee has been told about any medical conditions resulting from exposure toblood or other potentially infectious materials which require further evaluation or treatment.

All other findings or diagnoses must remain confidential and shall NOT be included in the written report. If medical follow-up is indicated, please complete the medical follow-up form for each follow-up visit and return it to the address indicated.

Signature of Company Representative _______________________________

Date:_________________________

Name(s) of Affected Employees:____________________________________________________________________________________________________________________________________________-Page 2 of 2-

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Attachment E

Health Care Professionals Written Opinion For Post-Exposure Evaluation

Health Care Professionals

1. Employee Name:_____________________________________________ 2. Date of Incident:_____________________________________________ 3. Date of Office Visit:__________________________________________ 4. Health Care Facility Address:__________________________________ 5. Health Care Facility Telephone:________________________________

As required under the Bloodborne Pathogen Standard:

______ The employee named above has been informed of the results of the post-exposure health evaluation.

______ The employee named above has been told about any health conditions resulting from exposure to blood or other potentially infectious materials which require further evaluation or treatment.

______ Hepatitis B vaccination is ____ is not ____ indicated.

Signature of health care provider:_______________________ Date: ________

Printed or typed name of health care provider:___________________________

This form is to be returned to the employer, and a copy provided to the employee within 15 days.

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Attachment FBloodborne Pathogens (New Hire)

Determine if employee is part of the exposure group

Inform employee of potential exposure

Provide employee a copy of the Bloodborne

Pathogens Exposure Control Plan

Hepatitis B vaccination series made available within 10 days of hire

Medical evaluation and Hep B series provided upon

request.

Medical Evaluation and Hep B vaccination

documents kept on site and send to

Central Office HR

If employee declines Hep B series they

must complete the declination form

Declination form is kept on site and send to Central Office HR

Emplyee can request the Hep B series at

anytime after declining.

New employee is ready for daily tasks

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Attachment GBloodborne Pathogens (Post Exposure)

Contact ACDAF immediately. ACDAF

reviews the BBP written plan to ensure proper

steps are followed

Immediate confidential medical evaluation

provided for employee

Employee provided with form letter from the BBP

plan to present to Physician

ACDAF assists employee with an Employee Work Injury and Illness Report

ACDAF will provide Physician a copy of: BBP

Plan, OSHA standard, routes/circumstances of exposure, source blood

test if available, employee medical records including

vaccination status

ACDAF completes the Employee First Report of

Injury or Disease Form

ACDAF/Supervisor complete the Supervisor's

Accident Analysis and Prevention Form

Physcian provides written opinion within 15 days of evaluation to employee

and ACDAF

Incident report forms will be shared with Worker

Comp. Coordinator

ACDAF, Supervisor and Worker Comp. Coordinator will monitor the employee treatment plan and

progress

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