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DEPARTMENT OF EDUCATION
STATE OF HAWAII
BLOODBORNE
PATHOGENS
EXPOSURE CONTROL PLAN
December 5, 2007
CONTENTS
Addendum Listing....................................................................................i
I.
Introduction....................................................................................1
II.
Occupational Exposure: Questions and Answers..........................2
III.
Exposure Determination................................................................7
IV.
Infection Control Guidelines........................................................10
V.
Exposure Control Plan for Employees.........................................15
A. Procedures to Prevent the Transmission of Bloodborne
Disease in the Workplace........................................................15
B. Procedures for Post-Exposure Evaluation and Follow-Up.....17
C. Procedures for Operational and Medical Records
Maintenance...........................................................................22
VI.
Hepatitis B Vaccination ...............................................................24
VII. Employee Training.......................................................................25
VIII. Confidentiality..............................................................................27
ADDENDUM
A.
(Pg. 28)
OSHA Fact Sheet –Hepatitis B Vaccination –
Protection for You
B.
(Pg. 29)
Hawaii Administrative Rules, Title 12, Department of Industrial
Relations, Subtitle 8, Division of Occupational Safety and Health,
Part 8, Health Standards, Chapter 205.1, Bloodborne Pathogens
C.
(Pg. 30)
OSHA Fact Sheet – Protecting Yourself When Handling
Sharps
D.
(Pg. 31)
OSHA Fact Sheet – Holding the Line on Contamination
E.
(Pg. 32)
OSHA Fact Sheet –Personal Protective Equipment
Cuts Risk
F.
(Pg. 33)
OSHA Fact Sheet—Reporting Exposure Incidents
G.
(Pg. 34)
Form UP 110: Employee Exposure Report
H.
(Pg.35)
Form UP 100: Exposure Incident Evaluation
Report
I.
(Pg. 36)
Form UP 105: Employee Vaccination Status
J.
(Pg. 37-38)
Form UP 115: Training Record
K.
(Pg. 39)
Form UP 120: Refusal To Consent to Hepatitis B
Immunization
L.
(Pg. 40)
Form WC-1: Employer’s Report of Industrial Injury
M
(Pg. 41-42)
Form UP 125: Source Person Consent for HBV
and HIV Testing and Disclosure Following
Employee Exposure and Procedure and Directions for Form UP
125 Identification and Documentation of the Source Individuals(s)
N.
(Pg. 43-44)
Form UP 130: Baseline Testing for Exposed Employee and
Procedure and Directions for Form UP 130
O.
(Pg. 45)
Form UP 140: Category I and II Determination; School/
Office List
P.
(Pg. 46)
Form UP 140: Exposure Determination List
Q.
(Pg. 47)
Standard Memorandum to Health Care Professional (with
Enclosures)
HAWAII DEPARTMENT OF EDUCATION
BLOODBORNE PATHOGENS EXPOSURE CONTROL PLAN
I.
INTRODUCTION
Employees in the educational workplace are often exposed to people with infectious
diseases such as upper respiratory infections and common childhood diseases. In
addition, some employees may occasionally be at risk for contracting infections from
exposure to contaminated blood or Other Potentially Infectious Materials (OPIM), which
may cause more serious diseases.
A variety of harmful microorganisms may be transmitted through contact with infected
human blood, Hepatitis B Virus (HBV) and Human Immunodeficiency Virus (HIV),
however, have been shown to be responsible for infecting workers who, in the course of
their work, were exposed to human blood and certain other body fluids containing these
viruses, through routes like needle stick injuries and direct contact of mucous membranes
and non-intact skin with contaminated blood or OPIM.
The prevailing scientific and medical view is that the overall risk for transmission of
HIV or HBV in the normal school/office workplace is very small. These viruses are
not transmitted through casual workplace contact. However possible transmission is still
a concern for employees whose jobs require them to be exposed to the blood or OPIM of
another person. All employees also need to be informed about bloodborne pathogens and
the need to avoid or otherwise protect themselves from transmission risk under conditions
where accidents or other circumstances place them in proximity to or require the handling
of blood or OPIM.
The State of Hawaii Division of Occupational Safety and Health HIOSH issued new
standards designed to reduce the risk of occupational exposure to known (HBV and HIV)
and other as yet unknown diseases transmitted by blood. Occupational exposure is
defined as "reasonably anticipated skin, eye, mucous membrane or other contact
with blood or other potentially infectious materials that may result from the
performance of an employee's duties." The regulations require employers to take
steps to protect their employees from exposure to these bloodborne infections.
The purpose of this plan is to prevent on-the-job employee exposure to bloodborne
pathogens through the practice of Universal Precautions, a continual program of
orientation, training, procedural compliance; and to ensure prompt follow-up care of
employees exposed to another person’s blood, body fluids or other infectious materials
while performing work-related tasks.
Bloodborne Pathogens Exposure Control Plan
Department of Education
December 5, 2007
Page 2
II.
OCCUPATIONAL EXPOSURE: QUESTIONS AND ANSWERS
WHAT IS VIRAL HEPATITIS?
Viral hepatitis is an infection of the liver. Hepatitis B (one form of viral hepatitis) is
spread by contact with blood or body fluids from people infected with the virus.
WHAT ARE THE SIGNS AND SYMPTOMS OF HEPATITIS?
One third of people with hepatitis have no symptoms. One third has "flu-like" symptoms
such as fatigue, body aches and fever. One third has a more serious course: jaundice,
abdominal pains and diarrhea, which can lead to liver failure and death. The virus infects
people of all ages and every year about 200,000 people are newly infected in the United
States. Of this 200,000, 90% eventually recover and clear the virus, but over 11,000 will
have to hospitalized and over 20,000 (10%) will become chronically (permanently)
infected with the virus. These people may develop chronic hepatitis, cirrhosis, and liver
cancer. About 1.25 million people in the United States have chronic HBV infection and
more than 4,000 people die each year from hepatitis B related liver disease.
WHAT IS AIDS?
Acquired Immune Deficiency Syndrome (AIDS) is caused by the Human Immune
Deficiency Virus, HIV, which gradually destroys the body's immune system, rendering it
susceptible to infection.
WHAT DOES IT MEAN TO BE HIV POSITIVE?
A person who is HIV positive has been infected by the HIV virus. The presence of HIV
antibodies is confirmed by blood tests. Not all people who are exposed to the virus will
become infected with it. The HIV antibody test usually becomes positive within six
months of exposure, but the time may vary from six weeks to a year.
WHAT ARE THE SYMPTOMS OF AIDS?
Most patients have no symptoms for a period of time after being infected with the virus.
Prior to developing "full- blown" AIDS, patients may have fever, enlarged lymph nodes,
weight loss, diarrhea, fatigue, or fungal infections of the mouth or esophagus. Generally,
Bloodborne Pathogens Exposure Control Plan
Department of Education
December 5, 2007
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people with AIDS show signs and symptoms which relate to the infections and cancers
that they acquire as a result of the deterioration of their immune system by HIV.
In 2005, the estimated number of diagnoses of AIDS in the United States and dependent
areas was 45,669. The cumulative estimate number of diagnoses of AIDS through 2005
in the United States and dependent areas was 988,376. In 2005, the estimated number of
deaths of persons with AIDS in the United States and dependent areas was 17,011. The
cumulative estimated number of deaths of persons with AIDS in the United States and
dependent areas through 2005 was 550,394.
IS THERE A VACCINE TO PREVENT AIDS?
As of now, there is no cure for the disease and no vaccine to prevent infection.
HOW ARE AIDS AND HEPATITIS B TRANSMITTED?
Transmission of both HIV and HBV require direct contact with or parenteral inoculation
of blood products or OPIM.
Both HBV and HIV have 4 proven routes of transmission:
PARENTERAL
Through an open wound, puncture of the skin, IV drug
use, transfusion, etc.
MUCOUS
MEMBRANE
Splashing body fluid in eyes or mouth
SEXUAL
Intercourse
PRENATAL
By mother to child through placenta
There is no evidence that either HBV or HIV is transmitted by casual contact or by
contaminated food or drinking water. Although both viruses have similar modes of
transmission, the risk of HBV infection following a needle stick is much higher, 6% to
30%, compared to the risk of HIV infection, which is less than 1%. BOTH HBV AND
HIV APPEAR TO BE INCAPABLE OF PENETRATING INTACT SKIN.
Bloodborne Pathogens Exposure Control Plan
Department of Education
December 5, 2007
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WHICH BODY FLUIDS ARE INFECTIOUS?
HIV has been isolated from virtually every body fluid. However, only blood and blood
products, semen, and vaginal secretions have been directly linked to transmission of HIV.
Contact with fluids such as feces, urine, nasal secretions, sputum, sweat, tears, and
vomitus (unless containing visible blood), is associated with low or minimal risk of
exposure. However, ALL BODY FLUIDS AND TISSUES SHOULD BE
CONSIDERED CONTAMINATED WITH HBV OR HIV. All should be treated as if
infectious.
ARE PREGNANT EMPLOYEES AT GREATER RISK?
Pregnant school employees are not known to be at greater risk of contracting HBV or
HIV infection than employees who are not pregnant. However, if a woman develops
HBV or HIV infection during pregnancy, the infection can be transmitted to the unborn
infant through the placenta. Therefore, pregnant employees should be especially familiar
with and adhere strictly to precautions to minimize the risk of exposure to bloodborne
pathogens.
WHAT PRECAUTIONS SHOULD BE TAKEN TO PREVENT EXPOSURE?
People infected with HIV or other bloodborne pathogens cannot be readily identified by
school or health care employees. There is a period of time between infection with HIV
and the development of HIV antibodies when the virus cannot be detected by blood tests.
Therefore, a person who has tested negative for the HIV antibody may actually carry the
virus. Similarly, people can be unknowingly asymptomatic chronic carriers of Hepatitis
B. The federal Centers For Disease Control (CDC) recommends strict adherence to
UNIVERSAL BLOOD AND BODY FLUID PRECAUTIONS. In addition, HIOSH
requires that there be strict adherence to engineering and work practice controls, labeling
of hazardous wastes, and use of personal protective equipment. These measures are
designed to reduce the risk of exposure to bloodborne pathogens in the workplace.
WHAT IS MEANT BY UNIVERSAL PRECAUTIONS?
This is an approach to infection control. The basis of Universal Precautions is the concept
that ALL human blood and certain human body fluids from all people are considered
infectious and need to be handled with Universal Precautions at all times. Appropriate
personal protective equipment should be used whenever potential for occupational
exposure exists. In a normal school/office setting, the usual protective equipment consists
of disposable latex gloves.
Bloodborne Pathogens Exposure Control Plan
Department of Education
December 5, 2007
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SHOULD SCHOOL EMPLOYEES TAKE THE HEPATITIS B VACCINE?
The U.S. Public Health Service recommends the Hepatitis B vaccine to protect workers
who are at risk for exposure to patients' blood or OPIM. Employers are required by
HIOSH to provide the vaccine free of charge to employees at risk of exposure.
Employees at risk (Category I and II jobs) will be offered the vaccine or be required to
sign a waiver acknowledging their refusal. If an employee is in doubt, he/she should
consult his/her personal physician before deciding to take or refuse the vaccine.
IS THE HEPATITIS B VACCINE SAFE AND EFFECTIVE?
The Hepatitis B vaccine is safe and effective. It is administered in three (3) doses injected
into the arm. The second and third doses are given one (1) and six (6) months
respectively after the first dose. Most people develop high levels of antibodies to HBV
after the full series and are "protected." The incidence of side effects, if any, is very low
and usually consists of mild tenderness and redness at the site of injection. Low-grade
fever, rash, nausea and fatigue have been reported. No serious side effects have been
reported.
WHAT IS AN EXPOSURE CONTROL PLAN?
HIOSH requires all employers to develop a written Exposure Control Plan, which
outlines the steps that will be taken to eliminate or minimize exposure to infectious
materials. This plan includes an exposure determination, a list of procedures in which
occupational exposure can occur, and a protocol for evaluating any exposure incident.
Engineering controls, work practice controls, and the use of personal protective
equipment must be instituted to comply with HIOSH standards. This Plan is annually
reviewed, revised for applicable changes, and accessible to employees.
WHAT ARE ENGINEERING CONTROLS?
Engineering controls are facilities and/or containers, which isolate or keep hazardous
materials away from people. These include hand washing facilities and special containers
for disposal of hazardous wastes. Employers are required to provide and maintain these
items. Employees are required to use them properly.
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Department of Education
December 5, 2007
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WHAT IS PERSONAL PROTECTIVE EQUIPMENT?
This equipment includes gloves and other devices designed to protect employees from
direct contact with blood or other potentially infectious materials. Employers are required
to provide and maintain these items. Employees are required to use them properly.
WHEN SHOULD PERSONAL PROTECTIVE EQUIPMENT BE USED?
The equipment that should be worn depends on the task to be performed. Gloves should
be worn when performing any task where there is the potential for contact with blood,
body fluids or potentially infectious materials. Employees who are allergic to regular
gloves must be provided with hypoallergenic gloves or suitable alternatives. Face
protection (masks and eye protection) must be used if splashing can reasonably be
anticipated. Protective body clothing (gowns and aprons) must be worn if soiling is
likely. In the school/office setting, disposable latex gloves provide adequate protection.
WHAT ARE WORK PRACTICE CONTROLS?
These include rules ensuring that employees perform their duties in the safest way
possible.
They include:
1. Wear gloves when handling blood or OPIM.
2. Wash hands after removing gloves. Hand washing with soap and water is most
important in preventing the spread of disease.
3. Avoid eating, drinking, smoking, applying cosmetics and handling contact lenses in
work areas where contamination is likely.
WHAT SHOULD BE DONE IF AN EXPOSURE INCIDENT OCCURS?
Under 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. Immediate action must be taken to minimize the risk of contracting HIV,
HBV or other diseases. Employees and supervisors must follow the post exposure
incident procedures on page 17 of this plan.
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Department of Education
December 5, 2007
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III.
EXPOSURE DETERMINATION
This section identifies tasks and potential job categories within the Department of
Education in which it is reasonable to anticipate that an employee will have skin, eye,
mucous membrane, or parenteral contact with blood or other potentially infectious
materials (listed below). Exposure determination shall be made without regard to the use
of personal protective equipment.
Other Potentially Infectious Materials (OPIM)
BODY FLUIDS
 semen
 vaginal secretions
 cerebrospinal fluid
 synovial fluid
 pleural fluid
 pericardial fluid
 peritoneal fluid
 amniotic fluid
 any body fluid visibly contaminated with blood
 saliva in dental procedures
OTHER MATERIALS


Any unfixed tissue or organ (other than intact skin from a human living or dead)
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.
A small number of jobs within the school system, however, may require the occasional
treatment of injuries or contact with blood or other body fluids. Employees serving in
these jobs may need additional training, protective equipment and/or technical procedures
to perform such duties safely.
Bloodborne Pathogens Exposure Control Plan
Department of Education
December 5, 2007
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Category I: All job classification in that all employees in those job classification has
occupational exposure:









Athletic Health Care Trainers
School Heath Aides
Athletic Health Care Specialists
Registered Professional Nurses
School Security Attendants
School Custodians
Classroom Cleaners
Plumbers
CPR First Responders
Category II: Job classifications in that some employees have occupational exposure:
 Teachers and Educational Assistants who regularly and routinely serve severely
handicapped students who require frequent bodily care and clean-up.
 Teachers and Educational Assistants who serve other students who are prone
physically to constitute a bloodborne transmission risk.
 Special Education
 Houseparents
 Dorm Attendants
 Building Maintenance Workers
All tasks and procedures or groups of closely related tasks and procedures in that
occupational exposure occurs and that are performed by employees in job
classifications listed in Categories I and II above:






Providing first aid on a regular basis.
Providing health care on a regular basis.
Serving as a designated CPR first responder.
Cleaning up and disposal of human blood, body fluids or OPIM.
Assisting with breaking up student fights or altercations.
Tending to the needs of children that may necessitate exposure to body fluids
visibly contaminated with blood that is released when compressed.
 Instructing and caring for students who bite, scratch, or engage in other behaviors
that would place an employee at risk for exposure to human blood, body fluids or
OPIM.
 Repairing and maintaining plumbing fixtures in bathroom facilities that may
necessitate exposure to human blood, body fluids or OPIM.
Bloodborne Pathogens Exposure Control Plan
Department of Education
December 5, 2007
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Clarification:
According to this Exposure Control Plan, each school or office will identify all
employees who fall within Category I or Category II as defined above. It is NOT
intended that all teachers and educational assistants serving special education students be
automatically included in Category II. Employees serving students with mild to moderate
disabilities generally do not meet the criteria for Category II, unless they serve students
who are known to have a history of biting, scratching, or other behaviors that would lead
to breakage of the skin or otherwise present an imminent risk of transmitting blood, body
fluids or OPIM. Employees who work with students categorized, as those with severe
disabilities would more likely meet Category II criteria. This may include those working
with students identified as severely multiply handicapped (SMH), severely mentally
retarded (SMR), profoundly mentally retarded (PMR), autistic, deaf-blind, or learning
impaired (LI). The intent is to identify teachers and educational assistants who are
regularly and routinely exposed to students with bodily care and clean-up needs and who
would need special training in Universal Precautions to prevent exposure to bloodborne
pathogens.
Category III
Tasks and work assignments involve no exposure to blood or other potential infectious
materials. Category I tasks are not a condition of employment. No personal protective
equipment is needed.
Except for the specific job categories identified in Categories I and II above, all other
employees of the Department of Education fall within this category.
SPECIAL NOTE: Public Health Nurses (PHN), employed by the Department of Health, Public
Health Nursing Branch, provides the clinical supervision of the school health aides, effective July
1, 2007. Public Health Nurses must follow the “Bloodborne Pathogens Exposure Plan”
developed by PHNB of Department of Health. Specific training, special engineering controls,
and protective needs for the PHNB employees are addressed by DOH, PHNB Supervisors.
Bloodborne Pathogens Exposure Control Plan
Department of Education
December 5, 2007
Page 10
IV.
INFECTION CONTROL GUIDELINES
PURPOSE:
To prevent the transmission of bloodborne infectious diseases to students, school staff
and other department employees and to ensure that Universal Precautions are carried out
by all employees when in potential contact with a person's blood, other body fluids,
urine, amniotic fluid, saliva, sputum, feces, mucous membranes, open wounds and
articles and surfaces contaminated with these substances.
PROCEDURES:
A. 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.
B. HAND WASHING AND OTHER GENERAL HYGEIENE MEASUERS
1. Employees shall wash their hands thoroughly with soap and water whenever
hands become contaminated. Hand washing with soap and water is most
important in preventing spread of disease. They should also wash hands
frequently to prevent the spread of disease. For example, they should wash
their hands before drinking, eating, smoking, or handling contact lenses;
before and after assisting or training a student in toileting and feeding; after
going to the bathroom; after handling soiled diapers, menstrual pads, soiled
clothes or equipment; etc.
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Department of Education
December 5, 2007
Page 11
2. Employees shall wash hands immediately after removing gloves or other
personal protective equipment.
3. Employees shall, as soon as possible, wash hands and any other skin areas
with soap and water and flush mucus membranes with water when such areas
come in contact with blood or OPIM. In addition, all employees identified in
Categories I and II exposure risk shall be apprised of disinfectant kits
available at work sites. Antiseptic towelettes are supplied for use where handwashing facilities are not immediately available.
Note: Hand washing facilities are available in bathrooms in schools and office
buildings. If the use of a hand washing facility is not immediately feasible,
employees shall use either an appropriate antiseptic cleaner or antiseptic
towelette. Employees shall wash their hands as soon as possible with soap and
running water. If soap is not immediately available in one particular
bathroom, soap can be obtained from the health room or faculty bathrooms.
4. Eating, drinking, smoking, applying cosmetics or lip balm, and handling
contact lenses are prohibited in areas where there is a reasonable likelihood of
exposure to blood or other potentially infectious materials.
5. Food and drink shall not be kept in refrigerators, freezers, shelves, cabinets or
on countertops or bench tops where blood or other potentially infectious
materials are present.
6. All procedures involving blood or other potentially infectious materials shall
be performed in such a manner as to minimize splashing, spraying, spattering,
and generation of droplets of these substances.
7.
Mouth pipetting/suctioning of blood or other potentially infectious materials
is prohibited.
C. PERSONAL PROTECTIVE EQUIPMENT
1. Personal Protective Equipment is defined as specialized clothing or equipment
worn by an employee for protection against exposure to infectious materials.
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Department of Education
December 5, 2007
Page 12
Category I and II employees need to have personal access to a regular supply
of disposable latex gloves and certain other protective equipment depending
on the specific nature of their exposure tasks.
2. Disposable Gloves
a. Wear gloves when situations arise that hands may come in direct contact
with a person's blood, wound drainage, urine, saliva, sputum, feces,
vomitus, mucous membranes, open skin lesions, rashes, when performing
vascular access procedures or when cleaning articles, instruments or
surfaces contaminated by body fluids.
b. Change gloves after contact with each person. Wash hands when gloves
are removed.
c. Change gloves when visibly soiled or torn.
d. Gloves are not necessary when in contact with a person's intact skin.
3. Non-Disposable Type Gloves
a. Decontaminate for re-use if the gloves are in good condition.
b. Discard when gloves are cracked, peeling, torn, punctured or show other
signs of deterioration (whenever their ability to act as a barrier is
compromised).
4. Mask or Mouth Shield for Resuscitation
Use one-way valve mask or mouth shield when administering emergency
mouth-to-mouth resuscitation.
Bloodborne Pathogens Exposure Control Plan
Department of Education
December 5, 2007
Page 13
Notes:
1. Disposable latex gloves shall be made available to each Category I and II
employee and at school health rooms, first aid boxes and at other locations
deemed appropriate and necessary by the school principal or worksite
supervisor. Hypoallergenic gloves shall be made available to Category I
and II employees who are allergic to the gloves normally provided.
(Procedures to purchase and assure availability of disposable latex gloves
shall be determined at each worksite.)
2. A one-way valve pocket mask or mouth shield shall be made available at
school health rooms, in first aid boxes and at other locations deemed
appropriate and necessary by the school principal or worksite supervisor.
D. GENERAL HOUSEKEEPING
All equipment, environmental and working surfaces shall be cleaned and
decontaminated using an EPA approved disinfectant after contact with blood or
OPIM. The following disinfectants may be used:
1. Sodium hypochlorite--available as Clorox or Puree or any household bleach
(100 ppm available chlorine) diluted 1 part bleach to 10 parts water.
2. Isopropyl alcohol (70-90%).
3. Iodophor germicidal detergent--500 ppm available iodine wescodyne--30cc
per gallon water.
4. Amphyl solution--20cc per gallon.
E. REGULATED WASTE DISPOSAL
1. HIOSH definition: Regulated waste means liquid or semi-liquid or other
potentially infectious materials; contaminated items that would release blood
or OPIM in a liquid or semi-liquid state if compressed; items that is caked
with dried blood or OPIM and is capable of releasing these materials during
handling; contaminated sharps; and pathological and microbiological wastes
containing blood or OPIM.
Bloodborne Pathogens Exposure Control Plan
Department of Education
December 5, 2007
Page 14
2. Disposal
Disposable materials contaminated with blood or body fluids shall be placed
in a separate plastic closable bag or container, which will be tied or closed to
prevent leakage of fluids during handling, storage, transport or shipping and
disposed of in a trash receptacle. Warning labels or red bags or containers
shall be used in accordance with pages 10 and 11 of the HIOSH Standard
attached. If outside contamination of a regulated waste container occurs, it
shall be placed in a second container as indicated on page 7 of the HIOSH
Standard attached.
Biohazard labels are affixed to receptacles for disposal of contaminated
medical materials, i.e., sharp container.
3. Disposable latex gloves shall be worn while handling contaminated materials.
Bloodborne Pathogens Exposure Control Plan
Department of Education
December 5, 2007
Page 15
V.
EXPOSURE CONTROL PLAN FOR EMPLOYEES
PURPOSES:
To prevent on-the-job employee exposure to bloodborne pathogens through the practice
of Universal Precautions and a continual program of orientation, training, and procedural
compliance. To ensure prompt follow-up care of employees exposed to another person's
blood, body fluids or other infectious materials while performing work-related tasks.
School principals and designated administrators are responsible for implementing this
exposure control plan for employees at their school or office worksites.
A. PROCEDURES TO PREVENT THE TRANSMISSION OF BLOODBORNE
DISEASES IN THE WORKPLACE
1. EMPLOYEE RESPONSIBILITIES
Understands and practices the concept of Universal Precautions and follows
guidelines for infection control outlined in Section IV herein.
Attends required training sessions as required in Section VII herein.
Employees in Category I and II jobs are required to use protective equipment and
to follow special procedures when performing duties which require the handling
of blood or OPIM.
2. SCHOOL PRINCIPAL OR DESIGNATED ADMINISTRATOR
RESPONSIBILTIES
The school principal/designated administrator is responsible for infection control
and has the following responsibilities:
a. Orient current employees annually with this plan and any updates.
b. Provide for orientation of all new employees and annually thereafter to this
plan and provide HIV and HBV education.
c. Annually identify positions and list all incumbents with Category I or II
Exposure according to the established criteria (Form UP 140, see Addendum
Bloodborne Pathogens Exposure Control Plan
Department of Education
December 5, 2007
Page 16
O and P). It is recommended that an initial list be discussed with faculty and
staff before finalization. Notify the affected employees. Update the list as
necessary.
d. Provide annual training for all employees at no cost to the employee and
during working hours.
e. Document the employee orientation and training process with appropriate
forms, which indicate the dates of training sessions, program content and the
names of the people attending the training and job titles.
f. Be prepared to respond appropriately and thoroughly when an employee
reports known or suspected exposure (Refer to applicable procedures for postexposure evaluation and follow-up.)
g. Complete and maintain all records required by HIOSH relating to infection
control.
h. Establish a procedure for self-audits, with documentation, to assess
compliance with the protocol outlined in this document. Assess the
effectiveness of the school/office's exposure control implementation program
annually and initiate any necessary improvements.
i. Provide hand-washing facilities, which are readily accessible to employees.
j. When provision of hand-washing facilities is not feasible, the employee shall
be provided either an antiseptic cleaner or antiseptic towelette.
Bloodborne Pathogens Exposure Control Plan
Department of Education
December 5, 2007
Page 17
B. PROCEDURES FOR POST-EXPOSURE EVALUATION AND FOLLOW-UP
Please review HIOSH standard 1910.1030 (f) (3) for compliance requirements.
If an employee is exposed to blood or potentially infectious material (needle stick or
cut with contaminated equipment; splash of blood into eyes, mouth, nose or exposed
scratched/punctured/ cut skin; etc.), the following procedural steps shall be taken:
1. EMPLOYEE RESPONSIBILITIES
a. Seeks immediate first aid/wound care as needed. The area of exposure shall be
cleansed with soap and water or rinsed thoroughly with water as appropriate.
When possible, the employee shall do the washing/rinsing him/herself at the
earliest time.
b. Notifies his/her immediate supervisor about the exposure incident.
c. Obtains required forms and documents from his/her supervisor and seeks
assistance in completing appropriate portions of Form UP 110.
c. Seeks specified medical evaluation, counseling and necessary follow-up
treatment through personal physician within 24 hours of the exposure.
Transmits Form UP 110 Employee Exposure Report, Standard Memorandum
to Health Care Professional, Reporting Exposure Incidents (OSHA Facts) and
Form UP 130 Baseline Testing of Exposed Employee to the attending
physician. (This evaluation and treatment shall be cost-free to the employee
and his/her medical insurance carrier. Bills for services shall be submitted to
the DOE Workers’ Compensation Unit which identifies the Bloodborne
Pathogens related costs and the employee involved.)
Note: If consent for baseline HIV testing (Form UP 130) is not given initially,
informs the attending physician in writing of decision to change if willing to give
consent at later time within a 90-day period while the blood sample is kept in storage.
e. After receiving medical evaluation and counseling, decides on the necessity of
accepting offered treatment options including HBV and HIV baseline testing,
HBV vaccinations, Immune Gamma Globulin treatment, and Tetanus
prophylaxis.
Bloodborne Pathogens Exposure Control Plan
Department of Education
December 5, 2007
Page 18
f. Receives confidential information relating to the source individual's HBV and
HIV antibody test (if authorization is given), if available, and uses the
information to help decide on medical management options. Assumes
responsibility to maintain the confidentiality of this information.
2. PRINCIPAL/SUPERVISOR RESPONSIBILITIES
a. May seek the assistance of the School Health Aide and/or a Public Health
Nurse in responding to the reported exposure incident.
b. Obtains essential information from employee and immediately completes
appropriate sections of the Employee Exposure Report (Form UP 110, see
Addendum G) including the information on the employee's Hepatitis B
vaccination status and the source individual's HBsAg (HBV antigen) and HIV
status, if available. Provides this Form UP110, Employee Exposure Report
(see Addendum G) the Standard Memorandum to Health Care Professional
(see Addendum Q), Reporting Exposure Incidents (OSHA Facts – see
Addendum F) and Form UP 130, Baseline Testing of Exposed Employee (see
Addendum N) to the employee for the employee to take to his/her personal
physician.
c. Advises the employee regarding how to seek medical evaluation and followup. The employee will seek medical evaluation and treatment from a personal
physician and provide the physician with the required forms.
d. If appropriate and as time permits but within seven calendar days, prepares
Form WC-l, Employer's Report of Industrial Injury in accordance with
Standard Practice #5504. Note: For exposure only incidents, file the DOE
Accident Report only. Filing a Form WC-1 is not required for exposure only
incidents. The filing of this report is required if an employee suffers an injury
which causes absence from work for one day or more or requires medical
treatment beyond ordinary first aid.
Exposure Only (No WC-1): Blood exposure (splatter) with no actual
injury/illness (i.e. Bite breaking skin.) and not requiring medical treatment.
e. Investigates the exposure incident and completes an Exposure Incident
Evaluation (Form UP 100, see Addendum H) which will be
Bloodborne Pathogens Exposure Control Plan
Department of Education
December 5, 2007
Page 19
used to help refine or improve the effectiveness of the Exposure Control Plan
at the school/office.
The goal of this evaluation is to identify and correct problems in order to
prevent recurrence of a similar incident.
f. Upon receipt of the completed Form UP 110 and Form UP 130 from the
attending physician:
1) Provides the employee with a reproduced copy of both forms within 15
working days of completion of the evaluation.
2) Files a photocopy of both forms in the employee's confidential medical
file. See page 22 for records maintenance instructions.
3) Forwards both forms to Office of Human Resources for permanent filing.
g. At the earliest time, attempts to identify and document the source individual
(Form UP 125, see Addendum M) using the following general guidelines:
Obtains consent from the source individual or from someone legally
authorized to give consent on that person's behalf to test the source
individual's blood for HBV and HIV.
1) When the source-individual is already known to be infected with HBV or
HIV, testing need not be repeated.
2) If consent is not provided, establishes that the legally required consent was
refused and documents the circumstances directly on the form.
3) If consent is given to conduct testing, contacts the source person's personal
physician to have blood samples drawn and to conduct the laboratory
testing.
Note: Test results shall be returned by the laboratory directly to the source person's
attending physician. That physician will share the results of the tests with the source
person and forward a copy to the exposed employee's
Bloodborne Pathogens Exposure Control Plan
Department of Education
December 5, 2007
Page 20
attending physician. The test results shall remain confidential and shall be shared
only with the source person (or guardians) and the exposed employee.
3. ATTENDING PHYSICIAN'S RESPONSIBILITIES
a. Reads and follows instructions outlining physician's responsibilities on the
Standard Memorandum to Health Care Professional form and attachments
(Reporting Exposure Incidents -OSHA Facts, Form UP 110 Employee
Exposure Report, and Form UP 130 Baseline Testing of Exposed Employee).
b. Reviews Form UP 110. With the employee's assistance and cooperation,
reviews the nature of the bloodborne pathogen exposure incident and counsels
the employee with regard to resulting medical implications.
c. Explains, recommends, and offers treatment options as necessary based on the
nature of exposure.
d. Reviews Form 130 with the affected employee. Explains the employee's
consent options. Explains that the blood samples will be used to conduct
baseline testing for Hepatitis B antibodies. HIV antibody testing will also be
conducted only if the exposed employee specifically consents to such testing.
Seeks consent from the employee to permit baseline blood collection and also
to permit HIV antibody testing.
1) If consent is obtained, draws the blood sample(s) and sends the sample(s)
for appropriate laboratory testing.
2) If consent is not obtained to collect blood sample(s), establishes that the
legally required consent was not obtained and documents the
circumstances.
3) If the employee consents to baseline blood collection but does not give
consent for HIV testing at the same time, the attending physician will
draw two blood samples. One sample will be used to conduct baseline
testing without HIV testing. The other blood sample will be preserved by
the laboratory for at least 90 days. (If, within 90 days of the exposure, the
employee elects to have the baseline sample tested, the attending
physician shall authorize the HIV antibody testing on the stored blood
sample.)
Bloodborne Pathogens Exposure Control Plan
Department of Education
December 5, 2007
Page 21
Note: Test results shall be returned by the laboratory directly to the
attending physician. The results shall remain confidential and shall be
shared only with persons specifically authorized by the employee.
4) Upon receiving confidential results of testing, notifies employee of test
results.
e. Completes the portion of the Form UP 110 documenting that the employee
has been informed of the results of the evaluation and was given information
regarding other medical conditions resulting from the incident which may in
the future require further evaluation and treatment.
f. Returns completed Forms UP 110 and UP 130 to the school principal or office
supervisor. Retains photocopies of these completed forms for own records.
g. Bills all medical charges arising from these counseling and follow-up
procedures to the DOE Workers’ Compensation Unit, P.O. Box 2360,
Honolulu, HI 96804.
Bloodborne Pathogens Exposure Control Plan
Department of Education
December 5, 2007
Page 22
C. PROCEDURES FOR OPERATIONAL AND MEDICAL RECORDS
MAINTENANCE
Operational and medical records shall be maintained according to HIOSH
requirements as follows:
1. SCHOOL PRINCIPAL OR DESIGNATED ADMINISTRATOR
a. Establishes and maintains a file of separate, confidential administrative
records for each employee with (Category I or II) occupational exposure
and for each employee who experiences an exposure incident. The file
shall be maintained in a separate locked storage or cabinet with access
only by school principal, designated administrator or person(s) otherwise
granted access by law.
1) These administrative records shall contain (when applicable):







Employee's name and social security number;
Photocopy of Employee Vaccination Status Form (Form UP 105,
see Addendum I);
Photocopy of Employee Exposure Report (Form UP 110)
documenting the results of medical counseling and follow-up
procedures;
Photocopy of completed Bloodborne Pathogens Training Record
(Form UP 115, see Addendum J) identifying specific training
received by the employee;
Photocopy of completed Form UP 120, Refusal to Consent to
Hepatitis B Immunization (see Addendum K);
Photocopy of completed Form 125 (see Addendum M), Source
Person Consent for Hepatitis B Virus (HBV) and Human
Immunodeficiency Virus (HIV) Testing and Disclosure Following
Employee Exposure;
Copies of any other written materials available to the principal or
office supervisor pertaining to the person's bloodborne pathogen
exposure or follow-up procedures.
Bloodborne Pathogens Exposure Control Plan
Department of Education
December 5, 2007
Page 23
b. The administrative records shall be confidential and shall not be disclosed
without written permission from the affected individual except to the
principal or supervisor and other persons responsible for the maintenance
of the records or otherwise granted access by law.
c. The confidential administrative records shall be maintained for the
duration of the person's employment with the school or office. The
confidential administrative records shall be transferred to the Office of
Human Resources for storage upon the employee's permanent transfer or
severance of employment.
2. OFFICE OF HUMAN RESOURCES
Confidential administrative records procedurally forwarded to the Office of
Human Resources shall be maintained by the Office of Human Resources for
the duration of individual's employment plus 30 years. Such confidential
administrative records shall be properly protected in separate files and shall
not be filed with the person's personnel records.
Bloodborne Pathogens Exposure Control Plan
Department of Education
December 5, 2007
Page 24
VI.
HEPATITIS B VACCINATION
All employees who have been identified as having Category I and II job exposure
(refer to Section III, pages 7, 8 and 9) will be offered the hepatitis B vaccination
series at no cost. In addition, all employees, regardless of their job exposure
category, will be offered post-exposure evaluation and follow-up at no cost should
they experience an exposure incident on the job.
All medical evaluations and procedures including the hepatitis B vaccination
series, whether prophylactic or post-exposure, will be made available to the
employee at a reasonable time and place. This medical care will be performed by
or under the supervision of a licensed physician, physician's assistant or nurse
practitioner. Medical care and vaccination series will be according to the most
current recommendation of the U.S. Public Health Service.
All laboratory tests will be conducted by an accredited laboratory at no cost to the
employee.
The vaccination is a series of three (3) injections. The second injection is given
one (1) month from the initial injection. The final dose is given six (6) months
from the initial dose. At this time a routine booster dose is not recommended, but
if the U.S. Public Health Service, at some future date recommends a booster, it
will also be made available to exposed employees at no cost.
The vaccination will be made available to employees with Category I and II job
exposure after they have attended training on bloodborne pathogens and within 10
working days of initial assignment. The vaccination series will not be made
available to employees who have previously received the complete hepatitis B
vaccination series; to any employee who has immunity as demonstrated through
antibody testing; or to any employee for whom the vaccine is medically
contraindicated. Any exposed employee who chooses not to take the hepatitis B
vaccination will be required to sign Form UP 120 indicating their refusal to
consent to hepatitis B immunization.
Bloodborne Pathogens Exposure Control Plan
Department of Education
December 5, 2007
Page 25
VII. EMPLOYEE TRAINING
School Principals or Designated Administrators are responsible for training employees
regarding bloodborne pathogens at the time of initial hire and annually thereafter. The
following content will be included:
1.
Explanation of and access to the HIOSH bloodborne pathogens standard
essentially requiring employers to follow procedures (using the concept of
"Universal Precautions") to protect their employees on the job from exposure to
bloodborne infections and this plan (see Addendum B);
2. General explanation of the epidemiology, modes of transmission and symptoms
of bloodborne diseases;
3. A review of UNIVERSAL PRECAUTIONS;
4. Explanation and access to this exposure control plan and how it will be
implemented;
5. Control methods that will be used to prevent/reduce the risk of exposure to blood
or other potentially infectious materials;
6. Explanation of personal protective equipment;
7. Information on procedures to use in an emergency involving blood or other
potentially infectious materials;
8. Explanation of post-exposure evaluation and follow up procedures;
9. Employees in Categories I and II shall receive training relating to special
preventive procedures and protective equipment required to be used while on the
job. This training shall also include information on the hepatitis B vaccination
program including the benefits and safety of vaccination;
Training resource: “Bloodborne Pathogens: In The School Setting” or comparable
training film and, this Plan.
10. Training records shall be maintained for 3 years from the date that training
occurred and shall include the following information:
Bloodborne Pathogens Exposure Control Plan
Department of Education
December 5, 2007
Page 26
a.
b.
c.
d.
11.
The date of the training sessions;
The contents or summary of the training sessions;
The names and qualifications of the persons conducting the training; and
The names and job titles of all persons attending the training sessions.
Employees must be provided with an opportunity for interactive questions and
answers with the person conducting the training session.
Bloodborne Pathogens Exposure Control Plan
Department of Education
December 5, 2007
Page 27
VIII. CONFIDENTIALITY



All information and communications (written or verbal) regarding an individual's
HIV status shall be treated with strict confidentiality and shall not be released or
made public upon subpoena or any other method of discovery without specific
release as required by law .
All information and communications must be maintained in an individual’s file in
a separate locked storage or cabinet, which is clearly designated as confidential.
All persons informed of a student's or employee's HIV status may not pass this
information on to anyone else without the specific written consent of the affected
person, parent or legal guardian. Violations of confidentiality may result in
personal penalties of $1,000 up to $10,000 per violation.
Legal Reference: HRS 325-101
ADDENDUM A
ADDENDUM B
Universal Precautions
Form UP 110
ADDENDUM G
Page 34
CONFIDENTIAL
DEPARTMENT OF EDUCATION
STATE OF HAWAII
EMPLOYEE EXPOSURE REPORT
Employee’s Name: ______________________________________________________________
Position: _____________________________ Date of Exposure: _________________________
Social Security No. (last 4 digits only): ________ Date Reported: ________________________
Employee’s description of exposure incident (include circumstances and route of exposure):
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Employee Information:
Hepatitis B Vaccination Status:
( ) Not Vaccinated
(
) Vaccinated, completion date: _______________________,
Serum antibody titer:
Date: ________________
Results: __________________________
Tetanus immunization:
Date: ____________________________________________________
Other relevant health information:___________________________________________________
______________________________________________________________________________
Contact Source Information:
Contact Source person(s): ( ) Known
( ) Unknown
Status (if known): HBSAg ________________ HIV _______________ Other ______________
Physician’s Statement (include recommendations re. indications and receipt of Immune Gamma Globulin,
Hepatitis B vaccine, Tetanus prophylaxis):
______________________________________________________________________________
______________________________________________________________________________
I have examined this person regarding the incident described above and have informed him/her of the
results of my evaluation and about any associated medical condition which require further evaluation and
treatment.
___________________________
Date
_______________________________________
Physician’s signature
_______________________________________
Physician’s name (print)
Universal Precautions
Form UP 100
ADDENDUM H
Page 35
DEPARTMENT OF EDUCATION
STATE OF HAWAII
EXPOSURE INCIDENT EVALUATION
Employee’s Name: ________________________________ Position:______________________
Date of Exposure Occurrence: __________________ Date Reported: ______________________
Employee’s description of exposure incident (include circumstances and route of exposure):
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
In relation to this exposure, present engineering controls were:
( ) Adequate
( ) Inadequate ( ) If inadequate, explain: ________________________
______________________________________________________________________________
______________________________________________________________________________
In relation to this exposure, present work practice controls were:
( ) Adequate
( ) Inadequate ( ) If inadequate, explain: ________________________
______________________________________________________________________________
______________________________________________________________________________
In relation to this exposure, personal protective equipment in use was:
( ) Adequate
( ) Inadequate ( ) If inadequate, explain: ________________________
______________________________________________________________________________
______________________________________________________________________________
Evaluate the cause of the exposure:
( ) Lack of resource (procedures, equipment, control)
( ) Lack of employee knowledge (procedures)
( ) Failure to follow procedures
( ) Cause beyond employee/employer control
( ) Other (Explain) ____________________________________________________________
______________________________________________________________________________
Recommendation to prevent future exposure: _________________________________________
______________________________________________________________________________
_____________________
Date
_____________________________
Signature
___________________
Title
Universal Precautions
Form UP 105
ADDENDUM I
Page 36
DEPARTMENT OF EDUCATION
STATE OF HAWAII
EMPLOYEE VACCINATION STATUS
Employee’s Name: ___________________________________
Position:____________________________________________
Date:_____________________________
HEPATITIS B:
(
) Completed Hepatitis B vaccination (date) _______________________________
(
) Post vaccine HBsAb Screening done
Date: _______________
Results: ________________________
(
) Refused Hepatitis B Vaccine
Date last offered:_________________
(
) Already immune
(
) Documentation of vaccination (date): ___________________________________
(
) Documentation of screening (date): _____________________________________
TETANUS:
Date of last vaccination: __________________________________________________
MEASLES/NAPES/RUBELLA:
Date of last vaccination: __________________________________________________
_____________________
Date
_____________________________
Signature
___________________
Title
Universal Precautions
Form UP 115
ADDENDUM J
Page 37
DEPARTMENT OF EDUCATION
STATE OF HAWAII
BLOODBORNE PATHOGENS
TRAINING RECORD
Training Topic: _________________________________________________________________
Date of Training: ____________________ School/Office: __________________________
Name(s) of Trainer(s) and
Qualifications:__________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Contents/Summary:______________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
TRAINING ROSTER:
Name of Participant
Job Title
_______________________________________
________________________________
_______________________________________
________________________________
_______________________________________
________________________________
_______________________________________
________________________________
_______________________________________
________________________________
_______________________________________
________________________________
_______________________________________
________________________________
_______________________________________
________________________________
_______________________________________
________________________________
Universal Precautions
Form UP 115
ADDENDUM J
Page 38
TRAINING ROSTER (CONT’D)
Name of Participant
Job Title
_______________________________________
________________________________
_______________________________________
________________________________
_______________________________________
________________________________
_______________________________________
________________________________
_______________________________________
________________________________
_______________________________________
________________________________
_______________________________________
________________________________
_______________________________________
________________________________
_______________________________________
________________________________
_______________________________________
________________________________
_______________________________________
________________________________
_______________________________________
________________________________
_______________________________________
________________________________
_______________________________________
________________________________
_______________________________________
________________________________
_______________________________________
________________________________
_______________________________________
________________________________
_______________________________________
________________________________
_______________________________________
________________________________
_______________________________________
________________________________
_______________________________________
________________________________
_______________________________________
________________________________
_______________________________________
________________________________
_______________________________________
________________________________
_______________________________________
________________________________
Universal Precautions
Form UP 120
ADDENDUM K
Page 39
DEPARTMENT OF EDUCATION
STATE OF HAWAII
REFUSAL TO CONSENT TO HEPATITIS B IMMUNIZATION
1.
I have been advised by persons representing the Department of Education that
in the course of performing my usual duties as an employee of the State of Hawaii, I
maybe at risk of becoming infected with Hepatitis B Virus (HBV) as a result of exposure
to blood, body fluids or other contaminated materials. Hepatitis B infection may result in
permanent and/or life-threatening damage to my liver.
2.
I have further been advised that the Department of Education will make the Hepatitis B
vaccine available to me at no cost. This vaccine may significantly reduce the possibility
of my becoming infected with the virus.
3.
I personally assume the risk and consequences of my refusal to have the Hepatitis B
immunization.
4.
If in the future I continue to have occupational exposure to blood or other potentially
infectious materials and I want to be vaccinated with Hepatitis B vaccine, I can receive a
vaccination series at no charge to me. It is my responsibility to notify my supervisor if I
decide to be vaccinated.
5.
I have read this document in its entirety and I fully understand it.
Date: ______________________
Name:________________________________________
Please Print Legibly
_____________________________________________
Signature of Refusing Employee
_________________________________________
Witness to Signature
__________________________
Date
ADDENDUM L
SAMPLE
Universal Precautions
Form UP 125
CONFIDENTIAL
ADDENDUM M
Page 41
STATE OF HAWAII - DEPARTMENT OF EDUCATION
SOURCE PERSON CONSENT FOR
HEPATITIS B VIRUS (HBV) AND HUMAN IMMUNODEFICIENCY VIRUS (HIV)
TESTING AND DISCLOSURE FOLLOWING EMPLOYEE EXPOSURE
SECTION I
EXPLANATION
An employee of the Department of Education has had an accidental exposure to your (or your child’s)
blood or body fluid. To assist in the medical management of the employee, and to comply with the
recommendations of the Centers for Disease Control (CDC), you are being asked to consent to the testing
of your (or your child’s) blood for antibodies to the Hepatitis B Virus (HBV) and Human
Immunodeficiency Virus (HIV). If you consent, a medical practitioner will be contacting you to arrange
for the drawing of blood samples through your personal physician. To ensure confidentiality, a code
number will be used instead of your name on the blood specimen before it is sent to a laboratory.
This consent form will be kept by school/office with the employee’s confidential medical file.
The coded test results will be released only to you, your physician, the exposed employee and employee’s
physician.
______________________________________________________________________________
SECTION II
CONSENT FOR HBV AND HIV TESTING
I have been given an explanation of what HBV and HIV tests mean, including the following:
1.
2.
The tests are to determine the presence or absence of HBV or HIV infection.
A false positive test (positive test for an individual who is negative) may occur
due to limitation of the screening procedure. A second test may be necessary to
confirm a positive test.
I agree to have my (or my child’s) blood tested for the presence of HBV and HIV infection. I have been
able to ask questions about the tests. Those questions were answered to my satisfaction. I understand the
benefits and risks of the tests.
I agree to have the blood test results released to myself, my physician, the exposed employee, and
employee’s physician.
_____________________________________
SOURCE PERSON OR LEGAL GUARDIAN SIGNATURE
_____________
DATE
___________________________________________ _____
__________________
SOURCE PERSON OR LEGAL GUARDIAN NAME (PRINT)
ADDRESS
TELE. NO.
____________________________________________
_______________
_____________
WITNESS SIGNATURE
DATE
TIME
_____________________________________________
WITNESS NAME (PRINT)
_____________
TIME
________________
Universal Precautions
ADDENDUM M
Page 42
STATE OF HAWAII
DEPARTMENT OF EDUCATION
PROCEDURE AND DIRECTIONS FOR FORM UP 125 IDENTIFICATION AND DOCUMENTATION
OF THE SOURCE INDIVIDUAL(S)
EXPLANATORY REMARKS
The State of Hawaii Division of Occupational Safety and Health (HIOSH) requires medical follow-up and
treatment for employees exposed to blood or other potentially infectious materials (OPIM) that can transmit
bloodborne pathogens such as Hepatitis B Virus (HBV) and Human Immunodeficiency Virus (HIV).
Employees who experience occupational exposure to blood or OPIM are often faced with difficult medical
management decisions ranging from submitting to vaccinations, Hepatitis B immune globulin, Serum
immune globulin and zidovudine (AZT) treatment to continuous testing for bloodborne diseases. These
employees would benefit greatly if they could receive test information to confirm or not confirm the source
person’s carrier status for HBV and HIV.
Privacy rights require that the voluntary consent of source individuals be obtained to disclose known test
results or to submit to HBV and HIB testing.
PRINCIPAL/ADMINISTRATOR’S RESPONSIBILITIES
One of the duties of the principal (or administrator non-school employees) following the reporting of an
exposure incident is to identify the source individual(s) and to obtain consent from the individual(s) (or
his/her legal guardian for minors) for his/her blood to be tested as soon as possible.
(1) The principal/administrator shall counsel the source individual (or legal guardian) and request
his/her written consent (Form UP 125) for HBV and HIV testing. If necessary, the source
person’s physician may be contacted for assistance in counseling and obtaining consent.
(2) If the source person consents, the principal/administrator shall arrange for laboratory evaluation.
If the source person refuses blood testing, the principal/administrator will document that consent
cannot be obtained. (Documentation should be noted on the Form UP 125 that the source person
was counseled, and refused to sign after receiving all the pertinent information. The time and date
of counseling and refusal should also be noted. The documented Form UP 125 should be filed
together with Form UP 110 in the employee’s confidential medical file.)
(3) Laboratory evaluation of the source person must be paid by the employer. The
principal/administrator shall arrange for laboratory and attending physician’s costs to be billed to
the Department of Education, Workers’ Compensation Unit, P.O. Box 2360, Honolulu, HI 96804.
Note: The source person’s testing following an employee’s occupational exposure cannot be
charged to the source person or his/her health insurance carrier. All post-exposure follow up costs
must be billed to and paid from designated Blood Pathogens Control funds administered by the
DOE WC Unit.
(4) This form shall be kept at the school/office together with the Form UP110 in the employee’s
confidential medical file.
Universal Precautions
Form UP 130
ADDENDUM N
Page 43
STATE OF HAWAII - DEPARTMENT OF EDUCATION
BASELINE TESTING OF EXPOSED EMPLOYEE
SECTION I
EXPLANATION
HIOSH’s bloodborne pathogens standard state that employees are entitled to free medical evaluation and
treatment as part of their post exposure care. The Department of Education (DOE) will refer an exposed
employee to his/her personal physician where the employee will be counseled about what happened and
how to prevent further spread of any potential infection. The employee will also receive appropriate
treatment in line with current U.S. Public Health Service recommendations.
The employee shall agree to allow the drawing of blood samples but may refuse permission for HIV testing
at that time. If the employee refuses to permit HIV will take two blood samples and arrange to have one
stored for 90 days in case the employee changes his or her mind about HIV testing.
The blood sample will be used to conduct baseline testing for HBV (and HIV if employee permits it)
antibodies. The tests provide baseline information from which appropriate exposure treatment such as
Hepatitis B immune globulin, AZT and Hepatitis B vaccination can be recommended.
______________________________________________________________________________
SECTION II
CONSENT FOR HBV AND HIV TESTING
I have read the above explanation. I have been able to ask questions about the tests. Those questions were
answered to my satisfaction.
I agree to have my attending physician collect blood sample(s) for testing as explained above.
I (check one)
_____
do
______
do not
consent to HIV antibody testing.
I agree to have my test results released to my physician who will advise me about the results and their
implications for my exposure treatment. I understand that the test results will remain confidential and will
not be released by my physician without my permission
_____________________________________
EMPLOYEE SIGNATURE
_____________
DATE
__________________________________________ _____________________
EMPLOYEE NAME (PRINT)
ADDRESS
_________________________________________
WITNESS SIGNATURE
_____________________________________________
WITNESS NAME (PRINT)
_____________
TIME
________________
TELE. NO.
____________________ ______________
DATE
TIME
Universal Precautions
ADDENDUM N
Page 44
STATE OF HAWAII
DEPARTMENT OF EDUCATION
PROCEDURE AND DIRECTIONS FOR FORM UP 130
BASELINE TESTING OF EXPOSED EMPLOYEES
DIRECTIONS:
The principal/administrator shall provide this form to the employee immediately at the time of
exposure reporting. The employee shall take the form to his/her personal physician where s/he
shall request an explanation of his/her consent options.
The attending physician shall assist the employee with explanations, respond to questions
regarding this form and oversee its proper completion.
The attending physician (if consent is given) shall collect the required blood sample(s) from the
exposed employee and arrange to have baseline testing done according to the Division of
Occupational Safety and Health (HIOSH) requirements. HIV antibody testing shall not be
performed without the employee’s consent.
FORM UP 130 DISTRIBUTION:
(1)
A photocopy shall be made at the time of form completion and shall be retained by the
attending physician.
(2)
The Form UP 130 shall be returned to the principal/administrator by the attending
physician together with the completed Form UP 110.
(3)
The principal/administrator shall distribute a photocopy of the completed Form UP 130 to
the exposed employee and retain another copy in the employee’s confidential medical
file.
(4)
Both forms UP 110 and UP 130 shall be forwarded to the Office of Human
Resources, Records and Transactions Section for permanent filing.
MEDICAL AND LABORATORY FEES:
Medical and laboratory fees for baseline and other post exposure testing shall be paid by the
employer through the Workers’ Compensation Unit. The attending physician shall bill all post
exposure medical expenses to the Department of Education, Workers’ Compensation Unit, P.O.
Box 2360, Honolulu, HI 96804.
GLOSSARY:
HBV Hepatitis B Virus
HIV Human Immunodeficiency Virus
AZT Zidovudine (HIV prophylactic)
Universal Precautions
Form UP 140
ADDENDUM O
Page 45
STATE OF HAWAII
DEPARTMENT OF EDUCATION
CATEGORY I AND II EXPOSURE DETERMINATION
SCHOOL/OFFICE LIST
______________________________________________________________________________
School/Office: ___________________________________________
NAME AND JOB TITLE/CLASSIFICATION
FOR EXPOSURE DETERMINATION
REMARKS
State reason(s) for
determination
Date:_______________
CATEGORY I
CATEGORY II
ADDENDUM P
Page 46
STATE OF HAWAII
DEPARTMENT OF EDUCATION
CATEGORY I AND II EXPOSURE DETERMINATION
SCHOOL/OFFICE LIST
Exposure Determination List
INSTRUCTIONS (Completed by Principal or Administrator)

Identify all employees with Category I and II Exposure.

List all positions/employees who meet the criteria for Category I and II designation.
EXPOSURE DETERMINATION CRITERIA
CATEGORY I:
Involves tasks and work assignments in which employees have a reasonable
likelihood of contact with blood, body fluids or other potentially infectious
materials (OPIM). The use of job-appropriate personal protective equipment
and other protective measures is required. Staff whose duties include
providing first aid/health care on a regular basis. Athletic Trainers, School
Health Aides, Athletic Health Care Specialists, Registered Professional
Nurses and employees serving as designated CPR first responders fall in this
category.
CATEGORY II:
Tasks and work assignments do not involve routine exposure to blood or
OPIM but may require performing unplanned Category I tasks. Appropriate
personal protective equipment must be available and these employees must
be familiar with protective measures. Staff whose duties include tending to
the needs of children that may necessitate exposure to body fluids visibly
contaminated with blood that is released when compressed; instructing and
caring for other students who bite, scratch, or engage in other behaviors that
would place one at risk for exposure to blood, body fluids or OPIM; cleaning
and disposal of blood, body fluids or OPIM; and assisting with breaking up
student fights and altercations. Teachers and Educational Assistants serving
severely handicapped students who require frequent bodily care and clean up
or other students who are prone physically to constitute a bloodborne
transmission risk, Special Education staff, House Parents, Dorm Attendants,
School Custodians, Classroom Cleaners and School Security Attendants fall
in this category.
CATEGORY III:
Tasks and work assignments involve no exposure to blood or other potential
infectious materials. Category I tasks are not a condition of employment. No
personal protective equipment is needed. Except for the specific job
categories identified in Categories I and II above, all other employees of the
Department of Education fall within this category.
ADDENDUM Q
Page 47
STATE OF HAWAII
DEPARTMENT OF EDUCATION
STANDARD MEMORANDUM TO HEALTH CARE PROFESSIONAL
BLOODBORNE PATHOGENS STANDARD
MEDICAL FOLLOW-UP FOR EXPOSURE INCIDENTS
Dear Licensed Physician:
The State of Hawaii, Department of Education employee identified o the attached Form UP110
has reported an occupational exposure incident in accordance with the U.S. Occupational Safety
and Health Administration’s (OSHA) Bloodborne Pathogens Standard and the State of Hawaii
Division of Occupational Safety and Health (HIOS). The employee is being referred to you, a
physician of his/her choosing, to obtain required medical counseling and appropriate follow-up
recommendations. We have enclosed copies of applicable procedures and other documents for
your information as follows:
1.
OSHA fact sheet Reporting Exposure Incidents.
2.
Department of Education Form UP 110 Employee Exposure Report for your completion and
return. Please inform the employee of the results of the evaluation, and explain, recommend
and offer treatment options as necessary based on the nature of the exposure and inform the
employee. Retain a copy of the form.
3.
Blank copy of the Department of Education Form UP 130 Baseline Testing of Exposed
Employee for your action. Please explain the employee’s consent options, that the blood
samples will be used to conduct baseline testing for Hepatitis B antibodies and that an HIV
antibody test will also be conducted only if the exposed employee specifically consents to
such testing. Please seek consent from the employee to permit baseline blood collection and
permit HIB antibody testing.
4.
Department of Education Policy and Procedures regarding medical follow-up for bloodborne
pathogen exposure incidents (copy of pertinent Plan pages).
5.
A copy of the HIOSH regulation 12-205.1.
OSHA standards and Section 325-101, Hawaii Revised Statutes require confidential handling of
medical information and records. The Department of Education as the employer is not authorized
to receive information regarding the diagnosis or treatment of this employee except as reported on
Form UP 110 and Form UP 130. These forms must be returned to the employer upon completion
and you are required to keep photocopies for your records.
Please return the completed forms and send the bill for specifically authorized medical and
laboratory follow-up services to the below identified Department of Education official/office:
Forms: Principal or Administrator’s Name:
School or Office Name:
School or Office Address:
Bills:
Department of Education, Workers’ Compensation Unit
P. O. Box 2360
Honolulu, Hawaii 96804