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Lead Custodian

Bloodborne Pathogen

Exposure Control Plan

Iredell-Statesville Schools

704-873-37551

Implementation

Bloodborne Pathogen Committee:Mike James – Safety and Compliance Office 704-978-2072Karen Kerley – Lead Nurse 704-832-2548Linda Gillon – Director of Classified Personnel 704-924-2037Kelly Marcy – Executive Director of Student Services 704-832-2542Eric Gilreath – Lead Custodian 704-873-3755

Medical Facility for Post Exposure and Follow Up Piedmont Healthcare Occupational Health611 Sullivan Road, Statesville NC 28677 704-878-9309Piedmont Healthcare Express Care125 Days Inn Drive, Mooresville NC 28117 704-660-9111

Facility for Hepatitis B Vaccinations and TitersIredell County Health Department318 Turnersburg Hwy, Statesville NC 28625 704-878-5300Iredell County Health Department610 E. Center Ave., Mooresville NC 28115 704-664-5281

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TABLE OF CONTENTS

PagePart 1 – Bloodborne Pathogens: Guidelines and Implementation Plan 3 – 4

Part 2 – Specific Application Definitions 4 – 7

Part 3 – Exposure Control Plan 7 Job Classification at Risk 7 - 8

Schedule of Implementation 9

Methods of Compliance Universal Precautions 10 Engineering and Work Place Controls 10 - 11

Hepatitis B Vaccination/Post-Exposure Evaluation and Follow-up11 – 13 Training and Information 14

Appendixes A – H 17 - 25

EmployeesIf you are exposed to body fluids, particularly blood, tell your immediate supervisor immediately.

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Bloodborne PathogensGuidelines and Implementation Plan for Iredell Statesville Schools

PART 1

1. Introduction

The OSHA Bloodborne Pathogens Standards applies to all job classifications where there is occupational exposure to blood or body fluids containing blood.

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.NOTE: This definition does not cover “Good Samaritan” acts (i.e. voluntarily aiding someone in one’s place of employment) that result in exposure to blood or other potentially infectious materials from voluntary assisting a fellow employee, although OSHA encourages employers to offer follow-up procedures to these employees in such cases.

This bloodborne Pathogens Standard policy and guidelines will apply to all employees who fall under the “Occupational Exposure” category as defined in Part 3 of this policy. Other employees may use the Employee Exposure Determination Questionnaire (Appendix A) to help them assess their status.

The purpose of this policy is to limit occupational exposure of employees to bloodborne and other potentially infectious body fluids and materials that may transmit bloodborne pathogens and lead to disease or death.

2. Responsibilities

The agency head shall ensure that:A. All elements of the Exposure Control Plan, including but not limited to

Exposure determination, work practice standards, Hepatitis B vaccination procedures, training requirements, and record keeping are met.

B. All employees have access to a copy of the agency’s Policy Directive And Exposure Control Plan.

C. This policy is reviewed and updated annually.

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3. Testing and Examination

An employee, who suspects that he/she has a blood or body fluid exposure may request to be tested at the school systems expense, provided the suspected exposure poses a significant risk of exposure as defined in the rules of the Health Services Commission. The source individual’s test results will be made available to the exposed employee with or without the source individual’s permission as long as significant risk of exposure has occurred (Communicable Disease Control Measure 15A NCAC19A.0202(4) adopted by the North Carolina Health Services Commission). Iredell-Statesville Schools strictly adheres to existing confidentiality rules and laws regarding employees with communicable diseases, including HIV or HIV-associated conditions.

4. Anti-Discrimination

Iredell-Statesville Schools does not discriminate against any applicant or employee who has or is suspected of having HIV infection or AIDS. An employee with HIV infection or AIDS may continue to work as long as the employee is able to satisfactorily perform the duties of the job and there is no medical evidence indication that the employee’s condition is a health threat to co-workers, students, or the public.

PART 2

1. Specific Application

This policy applies to all employees in Iredell-Statesville Schools. All occupational exposures to blood or other potentially infectious materials as defined in the definition section below are covered.

2. Definitions

For purposes of this section, the following shall apply:

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BLOOD means human blood, human blood components, and products made from human blood.

BLOODBORNE 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).

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 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 exposure ends of dental wires.

DECONTAMINATION means the use of physical or chemical means to remove, inactivate, or destroy bloodborne 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.

ENGINEERING CONTROLS means controls (e.g., sharps disposal containers, self-sheathing needles, safer medical devices, such as sharps with engineered sharps injury protections and needleless systems) that isolate or remove the bloodborne pathogens hazards 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 result from the performance of an employee’s duties.

HANDWASHING FACILITIES means a facility providing an adequate supply of running potable water, soap and single use towels r hot air drying machine.

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LICENSED HEALTHCARE PROFESSIONAL is a person whose legally permitted scope of practice allows him or her to independently perform the activities required by paragraph (f) Hepatitis B Vaccination and Post-exposure evaluation and Follow-up.

HBV means hepatitis B virus.

HIV means human immunodeficiency virus.

NEEDLELESS SYSTEMS means a device that does not use needles for:

(1) The collection of bodily fluids or withdrawal of body fluids after initial venous or arterial access is established; (2) the administration of medication or fluids; or (3) any other procedure involving the potential for occupational exposure to bloodborne pathogens due to percutaneous injuries from contaminated sharps.

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 INFECTIOUS MATERIALS means (1) The following human body fluids: semen, vaginal secretions, cerebrospinal fluid, synovial 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 through such events as needlesticks, human bites, cuts and abrasions.

PERSONAL PROTECTIVE EQUIPMENT is specialized clothing or

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equipment worn by an employee for protection against a hazard. General work clothes (e.g., uniforms, pants, shirts, or blouses) not intended to function as protection against a hazard is not considered to be personal protective equipment.

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 bloodborne 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).

3. At Risk Employees: Employees listed in at-risk job categories are those who because of their usual duties might be exposed to blood or other potentially infectious fluids as an integral part of performing occupational tasks. Therefore, it is reasonable to anticipate that exposure may occur. These employees are required by law to receive Blood borne pathogen training within 10 working days of employment and annually if job duties remain the same. At risk employees should also receive the hepatitis B vaccine series and titer, or sign a hepatitis B declination form.

The following table outlines examples of jobs considered to have occupational exposure, the tasks causing risk, protective barriers, and engineering controls.

At risk employees could include:

School NursesCustodiansAthletic TrainersDesignated First RespondersAny employee who performs invasive special healthcare procedure on a daily basis involving contact with blood or other infectious body fluids.

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Collateral Positions:

These are employees that do not in their normal work routine have exposure to blood or body fluids but there is a potential for exposure when performing collateral duties. The identification of occupational exposure through collateral duties permits the employer to provide hepatitis B vaccine series to those employees on a post exposure basis.

Collateral Positions could include:

AdministratorsBus DriversCoachesEpiPen RespondersSelf-Contained Exceptional Children’s Teachers and Teacher AssistantsSpeech Pathologist Teachers and Teacher Assistants

“Good Samaritan” acts, such as a teacher or secretary rendering assistance to an accident victim and other exposures that cannot be anticipated, do not constitute at-risk for occupational exposure. Employees who render such assistance shall be entitled to the same post-exposure follow-up as employees who are at-risk for occupational exposure to bloodborne pathogens.

The hepatits B vaccination series shall be offered (immediately and within 24 hours of the exposure incident) to any unvaccinated employee having collateral exposure who has rendered assistance in any situation involving the presence of blood or other potentially infectious materials on a post-exposure basis. Employees who decline the hepatitis B vaccination must sign the Iredell-Statesville Schools Hepatitis B Vaccination Declination Form

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Schedule for Implementing and Reviewing Exposure Control Plan

Activity Scheduled Completion Date

Actual Completion Date

Adopt policy, review guidelines August, 1993 August, 1993Assign responsibility for monitoring August, 1993 August, 1993Determine which employees are at risk of occupational exposure. September, 1993 September, 1993

Establish what engineering control protective equipment are needed, and make appropriate purchases.

September, 1993 September, 1993

Develop training September, 1993 April, 1994Implement training September, 1993 April, 1994Complete annual survey of workplace September, 1993

June 1994-95Complete annual review of policy 1993 September, 1994Reviewed/Revised July, 1995Reviewed/Revised July, 1996Reviewed/Revised July, 1997Reviewed/Revised July, 1998Reviewed/Revised August, 2000Reviewed/Revised July 25, 2001Reviewed/Revised July, 2003Reviewed/Revised July, 2005Reviewed/Revised July, 2006Reviewed/Revised July, 2008Implement new training and revised Exposure Control Plan

May, 2010

Reviewed/Revised Dec, 2016 February, 2017

Reviewed/Revised Aug, 2017 Aug 9, 2017Reviewed/Revised Aug, 2018

9Methods of Compliance

A. Universal PrecautionsUniversal Precautions as outlined by the Centers of Disease Control shall be observed to prevent contact with blood or other potentially infectious materials. Under circumstances in which differentiation between body fluid types is difficult or impossible, all body fluids shall be considered potentially infectious materials.

B. Engineering and Work Practice ControlsEngineering and work practice controls shall be used to eliminate or minimize employee exposure. Where occupational exposure remains after institution of these controls, personal protective equipment shall also be used. These engineering controls shall be effectiveness.Hand WashingEmployers shall provide hand washing facilities which are readily accessible to employees. When provision of had washing facilities is not feasible, the employer shall provide either an appropriate antiseptic hand cleanser in conjunction with clean cloth/paper towels of antiseptic towelettes. When antiseptic hand cleansers or towelettes are used, hands shall be washed with soap and running water as soon as feasible. Employers shall ensure that employees wash hands and any other shin with soap and water, or flush mucous membranes with water immediately or as soon as feasible following contact of such body areas with blood or other potentially infectious materials.Contaminated Needles and Other Contaminated SharpsContaminated needles and other contaminated sharps shall not be bent, recapped, sheared, or broken before disposal, with the following exceptions:

The employer can demonstrate that no alternative feasible or that such action is required by a specific medical procedure; and/or

Such recapping or needle removal must be accomplished through the use of mechanical device or a one-handed technique.

Immediately or as soon as possible after use, contaminated sharps shall be placed in appropriate containers for disposal. These containers shall be: (1) puncture resistant, (2) labeled or color-coded in accordance with this

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policy, and (3) leak proof on the sides and bottom. Warning labels shall be affixed to containers of regulated waste and containers used to store, transport or ship blood or other potentially infectious materials. Labels shall include the biohazard legend.Work Practice Controls means controls that reduce the likelihood of exposure by altering the manner in which a task is performed (e.g., diapering students unable to control bodily excretion functions, requiring that glass be picked up with tongs or dust pans and brushes).

4. Hepatitis B Vaccination/Post-Exposure Evaluation and Follow-up

A. GeneralIredell-Statesville Schools shall make available the Hepatitis B vaccine and vaccination series to all employees who have occupational exposure risk and post-exposure. Iredell-Statesville Schools shall ensure that all medical evaluations and procedures including the Hepatitis B vaccine and vaccination series and post-exposure evaluation and follow-up shall be: available at no cost to the employee; made available to the employee at a reasonable time and place; performed by or under the supervision of a licensed physician or by or

under the supervision of another licensed healthcare professional; and provided according to recommendation of the U. S. Public Health

Service current at the time these evaluations and procedures take place.

B. Hepatitis B VaccinationHepatitis B vaccination shall be made available after the employee classified as having occupational exposure has received the training required by the policy, and within ten (10) working days of initial assignment, unless the employee has previously received the complete Hepatitis B Vaccination series, antibody testing has revealed that the employee is immune or the vaccine is contraindicated for medical reasons. Any employee classified as having occupational exposure may decline the Hepatitis B Vaccination by signing the declination form. If an employee initially declines the vaccination, but later decides to accept it, the

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vaccination shall be made available free of charge, and the employee shall sign the Administration Form.

After completion of the Hepatitis B Vaccine series, the employee will have a Hepatitis B titer drawn within 6-8 weeks. Should this Hepatitis B titer be negative, a booster dose of Hepatitis B vaccine will be given and the Hepatitis B titer would be rechecked 6-8 weeks later. If the second titer is still negative, then completion of the second Hepatitis B series will take place and a third Hepatitis B titer drawn 6-8 weeks after completion of the second series. Anyone completing the second Hepatitis B vaccine series with a continued negative titer is determined to be a non-converter and no further Hepatitis B vaccine will be administered. The employee would be counseled related to exposure control measure, personal protective equipment and lack of protection normally provided by the Hepatitis B vaccine.

C. Post-exposure Evaluation and Follow-upFollowing a report of an exposure incident, Iredell-Statesville Schools will make immediately available to the exposed employee a confidential medical evaluation and follow-up, including at least the following elements:(1) Documentation of the routes of exposure and the circumstances

under which the exposure incident occurred.(2) Identification and documentation of the source individual,

unless the employer can establish that identification is infeasible or prohibited by state or local law. The employer will assure that the source individual’s blood is tested as soon as feasible and after consent is obtained, in order to determine and document the HBV and HIV infectivity status. If consent is not obtained, the employer shall establish that legally required consent cannot be obtained. When the source individual’s consent is not required by law, the source individual’s blood, if available, shall be tested and the results documented. When the source individual is already known to be infected with HV or HIV status need not be repeated. The results of the source individual’s testing shall be made available to the exposed employee where not prohibited by state or local law,

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and the employee shall be informed of applicable laws and regulations concerning disclosure of the identity and infectious status of the source individual. According to Chris Hoke, Assistant State Health Director, legal consent to release test results to the exposed employee does not have to be given by the source individual, based on the Health Services, Commission’s Communicable Disease Control Measure 15A NCAC 19A.0202(4).

(3) Collection and testing of the exposed employee’s blood for HBV and HIV serological status will be done as soon as feasible and after consent is obtained.

(4) Post-exposure prophylaxis, when medically indicated, will be made available as recommended by the U.S. Public Health Service, counseling, and evaluation of reported illnesses will also be provided.

(5) Information will be provided to the healthcare professional responsible for the employee’s Hepatitis B vaccination as follows:a copy of the policy and the guidelines, a description of the exposed employee’s duties as they relate to the exposure incident, documentation of the routes of exposure and the circumstances under which exposures occurred, results of the source individual’s blood testing, if available, and all medical records relevant to the appropriate treatment of the employee including vaccination status which are the employer’s responsibility to maintain.

(6) The healthcare professional’s written opinion shall be obtained by the employer and provided to the employee within 15 days of the completion of the evaluation. The written opinion shall be limited to whether Hepatitis B Vaccination is indicated for the employee and if the employee has received follow-up shall be limited to the following information: The employee has been informed of the results of the evaluation; the employee has been told about any medical conditions resulting from exposure to blood or other potentially infectious materials which require further evaluation or treatment. All other findings or diagnoses shall remain confidential and shall not be included in the written report.

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D Training and Information

A. GeneralIt is recommended that all employees be offered training Opportunities on the basic knowledge and prevention principles forHBV and HIV. These employees must be informed:

That they are not 1st Responders, and What procedures to follow (including who to call) in case

of an accident or event that would potentially expose them to blood or body fluids. Employees with occupational exposure are required to receive training that includes precautionary measures, epidemiology, modes of transmission, prevention of HBV and HIV, universal precautions, and reporting procedures. This training must be updated annually; new employees are required to train within ten (10) days of employment, or within ten (10) days from the time of the initial assignment of a task with occupational exposure potential.

B. Training Program ContentTraining programs for employees with occupational exposure will contain, but not be limited to the following:(1) A copy of the workplace policy and guidelines as well as a

copy of the OSHA Standard. The content of both shall be explained during training.

(2) An explanation of the epidemiology and symptoms ofbloodborne diseases.

(3) An explanation of the modes of transmission of bloodborne diseases.

(4) An explanation of the appropriate methods for recognizing task and other activities that may involve exposure to blood and other potentially infectious materials.

(5) An explanation of selection, the uses and limitation of practices that will prevent or reduce exposure to bloodborne pathogens, including appropriate engineering controls, workplace practices, and use of protective equipment.

(6) Information on the types, proper uses, locations, removal,handling, decontamination and/or disposal of protective equipment.

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(7) Information on the Hepatitis B vaccine, including information

on its usefulness, safety, and the benefits of pre-vaccination and post-vaccination.

(8) An opportunity for interactive questions and practice with the persons conducting the training sessions.

C. Recording Keeping and Surveillance(a) Types of records kept The following types of records will be kept:

(1) Training records, indicating the dates of training Sessions; the names, qualifications, and job titles of the trainer(s); the names job title, and work locations of training participants, and any relevant unanswered issues that were raised during training.

(b) Results of an annual workplace survey for compliance with practices and use of protective equipment. If noncompliance is noted, the conditions are to be documented along with corrective action taken.

(c) Incident of exposure records, noting the conditions associatedwith each incident of exposure, and evaluation of these conditions, any information from the exposed employee’s healthcare provider, and a description of any corrective measures taken to prevent a recurrence or other similar exposure.

(d) Medical records shall be established and maintained for eachemployee. This record shall include:

the name and social security number of the employee; a copy of the employee’s Hepatitis B Vaccination

records and medical records relative to the employee’s ability to receive vaccination or the circumstances of an exposure incident.

the employer’s copy of the healthcare provider’s written opinion; and

a copy of the information provided to the healthcare provider.

Specific requirements should not preempt North Carolina OSHA record keeping requirements.

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(e) Confidentially

Confidentially of the employee’s medical records will be maintained. The records will not be disclosed or reported to any person within or outside the workplace except as required by these policies and guidelines or as may be required by laws. employee’s medical and training records required by these policies and procedures will be provided upon requires for examination and copying to the subject employee and to anyone having written permission and consent of the subject employee.

(f) Duration of Maintaining RecordsTraining records will be maintained for three years. Employee’s medical records will be maintained for at least the duration of employment plus 30 years.

(g) SurveillanceA workplace survey will be conducted annually to monitor adherence to these policies and procedures. Any noncompliance and corrective actions taken will be noted.

(h) Iredell-Statesville School shall establish and maintain a Sharps Injury Log for the recording of percutaneous injuries from contaminated sharps. The information shall be recorded and maintained in such a manner as to protect the confidentiality of the injured employee. The type and brand of device involved in the incident, the department or work area where the exposure incident occurred and an explanation of how the incident occurred shall be recorded. The Sharps Injury Log shall be maintained for 5 years as required by OSHA’s regulations in 29 CFR 1960.73 for retention of records.

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APPENDIX A

EMPLOYEE EXPOSURE DETERMINATIONQUESTIONNAIRE

Date: ________________________________ Job Title: __________________________

Employee Name: _________________________________________________________

Social Security Number: ___________________________________________________

Purpose of Questionnaire - The purpose of this questionnaire is to assist your employer in determining your exposure potential to human blood, body fluids, or other infectious material. This determination is a requirement of your employer’s “Bloodborne Pathogens Policy,” and is required by the federal Occupational Safety and Health Administration (OSHA). Your employer will use the results of this questionnaire to: (1) plan and conduct employee training, and (2) to set up precautionary measures to prevent workplace exposure to blood, body fluids, or other potentially infectious materials.

Part 1 Does your job require you do any of the following as a specific condition of employment (does your job description specify that you do any of the following)?

YES NO

(A) Work directly with human blood, blood products, body fluids, or tissue products (Examples: laboratory technicians, emergency room physicians, nurses)(B) Give assistance to accident or injury victims at or away from the general area where you work, on a regular basis (Example: 1st Responders, emergency or rescue personnel)(C) Clean up blood, or other body fluids with visible blood (such as vomitus, urine) on a regular basis as part of my job (Examples: custodians or teachers who perform invasive procedures on a daily basis)(D) Your everyday job tasks do not cause you to work with or be in direct contact with blood or body fluids, but you may respond to unplanned events, such as helping a hurt student or co-worker who is sick (Example: Elementary teacher who helps student with cut finger, high school teacher who helps student with bloody nose)(E) Your job does not require you to be exposed to blood or

body fluidsPart 2 Determining Your Exposure Classification

Please put a check beside your classification, based on how you answered the questions in Part 1.

If you answered yes to these questions fromPart 1

You are in this category Check () Your Exposure Category Here

A, B and/or C Occupational ExposureD or E No Occupational Exposure

(even though you may have unplanned exposure)

Part 3 Listing Task That May Put You at Risk

If you are in the “Occupational Exposure” category, please list each task you do as a requirement of your job that may cause you to be exposed to blood, body fluids, or other potentially infectious materials.Check all types of exposure that apply.If you are in the “No Occupational Exposure” category, you may have some unplanned exposure potential, but that does not fall under OSHA definition of occupational exposure. You do not have to complete this section.

List Task Blood Body Fluids Contaminated Material

1.

2.

3.

4.

5.

Return to School Nurse within 10 days of being hired or job description changes.18

APPENDIX B

IREDELL-STATESVILLE SCHOOLSBLOODBORNE PATHOGENS EXPOSURE INCIDENT REPORT

This report is to be filled out before going to the physician and within 24 hours of exposure. This form and the Healthcare Professional’s Written Opinion Form go to the physician at the time of initial visit. These forms are used in conjunction with the Worker’s Compensation forms.

Employee’s Name: _________________________________ DOB ___________

School __________________________________________________________

Date & Time of Incident _____________________________________________

Yes No1. Was this:

A needlestick injury from a usedneedle? ____ ____

A bite resulting in broken skin? ____ ____2. Did someone else’s blood come in

contact with your body? ____ ____3. Did someone else’s blood come in

contact with your eyes, mouth orbroken skin? ____ ____

4. Did body fluid (saliva, vomit, urine, feces) from the other person come incontact with your body? ____ ____

5. Did this body fluid contain VISIBLEblood? ____ ____

6. Did this body fluid come in contact withyour eyes, mouth or broken skin? ____ ____

7. What personal protective equipment wereyou using?___none ___gloves ___mask ___goggles ___face shield___other (describe ___________________)

If employee goes to the doctor due to an exposure, fill in the following information. Have you received the Hepatis B vaccine series? ___Yes ___NO

Source’s Name _________________________ Phone No. _________________

If source is a minor, state parent/guardian name __________________________Source’s Physician _______________________ Phone No. _________________

19APPENDIX C

ANNUAL SURVEYBloodborne Pathogens Surveillance and Monitoring Form

Monitored by Principal:_____________________ Date: ________________

Corrective Action Completed by: _________________________ Date: ________

Reviewed by: ________________________________________ Date: ________

SURVEILLANCE AND MONITORING

1. Are staff using proper hand washing techniques?PARTIAL

YES NO N/A COMPLIANCE ______%

2. Are staff wearing gloves when performing techniques involving blood, body fluids or tissues?

PARTIAL YES NO N/A COMPLIANCE ______%

3. Are staff wearing gowns when soiling of clothing with infective matter is likely?

PARTIAL YES NO N/A COMPLIANCE ______%

4. Are staff wearing masks, face shields and/or eye wear when splashing of blood or body fluids is likely?

PARTIAL YES NO N/A COMPLIANCE ______%

5. Are staff complying with not recapping, bending, breaking, or manipulating of needles?

PARTIAL YES NO N/A COMPLIANCE ______%

6. Are staff using puncture-resistant containers to dispose of needles and other sharp object?

PARTIAL YES NO N/A COMPLIANCE ______%Explain %: _______________________________________________________

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APPENDIX D

IREDELL-STATESVILLE SCHOOLSHEPATITIS B VACCINE

IMMUNIZATION ADMINISTRATION FORM

Work Location: __________________________________________Name: _________________________________________________ Date of Birth: ____________________________________________Home Address: __________________________________________Home Phone: ___________________________________________City/State/Zip: ___________________________________________ Cell Phone: _____________________________________________

_______________________________________________________

Hepatitis B Immunization Administration Request

I have read the information provided to me by Iredell County Health Department concerning the Hepatitis B Vaccine. I have had the opportunity to ask questions about the benefits and risks of the Hepatitis B vaccinations. I understand that there is no guarantee that I will become immune and that there is a possibility that I will experience adverse side effects from the vaccine. I agree to receive the Hepatitis B vaccine. I have been advised that studies have not been conducted to determine the effect of the vaccine on a developing fetus and the safety of the vaccine to the developing fetus is not known.

Series complete at this time. No further vaccine needed.

Employee Signature: ____________________________ Date: _________________________________________

Vaccine Date ProviderHepatitis B #1Hepatitis B #2Hepatitis B #3Hepatits B Titer

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APPENDIX E

Hepatitis B Vaccination Declination Form

I understand that due to my occupational exposure to blood or other potentially infectious materials, I may be at risk of acquiring infection caused by the Hepatitis B Virus (HBV). I have been given the opportunity to be vaccinated with the Hepatitis B vaccine at no charge to myself. However, I decline Hepatitis B vaccination at this time. I understand that by declining this vaccine, I continue to be at risk of acquiring HBV, 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 at no charge to me.

Date: ________________________________________________

Employee: ____________________________________________

Witness: ______________________________________________

Return this form to the School Nurse or Karen Kerley, Lead School Nurse, A.D.R. Education Center

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APPENDIX F

IREDELL-STATESVILLE SCHOOLS CHECKLIST FOR COMPLIANCE WITH THE OSHA BLOODBORNE PATHOGENS STANDARDS

Have we addressed the following for employees who have occupational exposure to blood or body fluids (see definitions of occupational exposure and other potentially infectious materials, Part 2 and 3)?

Ensure that the worksite is maintained in a clean and sanitary condition.

Develop an Exposure Control Plan. Identify in writing all job classifications that involve occupational exposure, and

the tasks that put employees at risk of exposure. Create a schedule to meet the activities outlined in the exposure control plan,

and review it annually.Make sure your Exposure Control Plan includes Methods of Compliance. Methods of Compliance include:

Implementing Universal Precautions – treating all blood and body fluids as if infectious.

Developing engineering and work practice controls such as hand washing and labeling of contaminated waste.

Providing personal protective equipment for employees at no cost to the employees such as gloves, resuscitation bags or other equipment.

Insuring that all employees use appropriate protective equipment unless you have written justification for not doing so.

Provide all employees with occupational exposure the Hepatitis B vaccine Titer at no cost to the employees. A Declination Form must be signed by any employee who does not want the vaccine. The vaccine is required to be made available within 10 working days of initial an assignment.In the event of an exposure to infectious material, an employer must:

Provide post=exposure evaluation and follow-up, including lab tests at no cost to the exposed employee.

Make available immediately to the employee a confidential medical evaluation documenting the exposure, identifying and testing the source individual, and testing the employee’s blood upon consent for HIV and HBV.

Provide post-exposure prophylaxis, counseling and evaluation.

Provide hazard communication to employees, including warning labels on regulated trash and waste containers.Provide training to all employees with occupational exposure within 90 days of work assignments and repeated once a year.Maintain medical records and training records.

23Appendix G

Sharps Injury Log

School: _______________________________________________

Date Staff Type of Incident

Department or Work Area Incident

Occurred

Brief Description of How the Incident Occurred

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Appendix H

OSHA Regulated Staff Members (At-Risk for Blood/Body Fluids Exposure)School: ___________________ Year/Term: __________________

Staff Member Job Title Reason – At Risk

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