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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 Page 3 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 Page 4 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 Page 5 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. Bloodborne Pathogens Exposure Control Plan Department of Education December 5, 2007 Page 6 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. Bloodborne Pathogens Exposure Control Plan Department of Education December 5, 2007 Page 7 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 Page 8 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 Page 9 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. Bloodborne Pathogens Exposure Control Plan 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. Bloodborne Pathogens Exposure Control Plan 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