Bloodborne Pathogens
Exposure Control Plan
Office of Environmental Health & Safety
Iler 106
201 High Street
Farmville, VA 23909
434.395.2940
Revised: February 2014
LONGWOOD
UNIVERSITY
Office of Environmental Health, Occupational Safety
& Emergency Management
Standard Operating Guideline # SG-4
Bloodborne Pathogens Exposure Control Plan:
Table of Contents
Section
Page
I.
Introduction…………………………………………………………………….
2
II.
Responsibilities…………………………………………………………….......
2
III.
Exposure Determination……………………………………………………….
2
IV.
Methods of Implementation and Control…………………………………….
3
a. Universal Precautions……………………………………………………..
3
b. Engineering Controls and Work Practices………………………………
3
c. Personal Protection Equipment (PPE)……………………………………
4
V.
Sanitation……………………………………………………………………….
6
VI.
Sharps & Regulated Waste Management……………………………………
7
VII.
Hepatitis B Vaccine & Post-Exposure Evaluation and Follow-up………….
8
VIII. Warning Labels and Signs…………………………………………………….
10
IX.
Employee Information and Training………………………………………….
11
X.
Recordkeeping………………………………………………………………….
12
XI.
Plan Review……………………………………………………………………..
13
XII.
Document History………………………………………………………………
14
XIII. Appendices/Form
A. Category 1 – Job Classification expected to incur occupational exposure
15
B. Category 2 - Job classification that may incur occupational exposure……..
16
C. Sharps Injury Log……………………………………………………………….
17
D. Hepatitis B Vaccine Form……………………………………………………….
18
E. Employee Safety Recommendation Form……………………………………...
19
Version – February 2014
Page 1
LONGWOOD
UNIVERSITY
I.
Office of Environmental Health, Occupational Safety
& Emergency Management
Introduction:
The following written Bloodborne Pathogens Exposure Control Plan (the Plan) establishes the
requirements and procedures necessary to eliminate or minimize employee occupational
exposure to pathogenic microorganisms and other infectious materials. The exposure control
procedures herein have been developed and implemented to ensure that faculty and staff
personnel are knowledgeable of the disease causing pathogens potentially present in human
blood (e.g., HBV and HIV) and the specific measures to prevent or limit that exposure.
This Plan is designed and implemented to ensure conformance with the requirements of 29 CFR
Part 1910.1030 and to act as a quick reference guide to assist employees conducting first aid
and related emergency response or health care activities. A copy of the Plan is available for
review during new employee orientation and by any employee during normal working hours in
the following locations:
•
•
•
II.
Office of Environmental Health and Safety
Office of the Director of Facilities Management
Human Resources Department
Responsibilities:
Affected Longwood University employees are required to comply with the bloodborne
pathogens exposure control procedures and practices contained in this Plan. All duties or
activities involving the potential for exposure to blood or other potentially infectious
substances must be conducted in complete accord with the requirements and limitations
outlined within the Plan.
Violation of any Safety Rule is actionable under the Department of Personnel and Training
General Policy 1.60, entitled “Standards of Conduct”.
III.
Exposure Determination:
A review of Longwood University personnel duties and responsibilities was conducted in August
2003 to identify those employees that may incur occupational exposure (e.g., specific eye,
mouth or other mucous membrane, non-intact skin, or parenteral contact) to blood or other
potentially infectious materials (e.g., semen, vaginal secretions, cerebrospinal fluid, amniotic
fluid, unidentified body fluid, unfixed human tissue or organ, etc.). The exposure evaluation was
conducted without regard to the use of personal protective equipment.
The table contained in Appendix A outlines those employees that may be expected to incur an
occupational exposure.
Version – February 2014
Page 2
LONGWOOD
UNIVERSITY
Office of Environmental Health, Occupational Safety
& Emergency Management
The table contained in Appendix B outlines those job classifications in which some employees
may incur an occupational exposure and their job task and duties.
Note: Part-time, temporary, contract, and per diem employees are covered by the bloodborne
pathogens standard.
IV.
Methods of Implementation and Control
a) Universal Precautions
Universal precautions shall be observed at all times when the potential for contact with blood
or other potentially infectious materials exists. All blood shall be considered infectious
regardless of the perceived status of the source individual.
b) Engineering and Work Practice Controls
The following engineering and work practice controls shall be used as a first line of defense to
prevent or minimize employee exposure to blood or other potentially infectious materials:
Engineering and Work Practice Controls
1. Needles and other contaminated sharps shall not be bent, recapped or
removed and must be placed in a puncture resistant, color-coded/labeled and
leak-proof container immediately or as soon as possible after use.
2. Re-usable sharps that are contaminated with blood other potentially
infectious substances may not be stored or discarded in a manner that requires
the placement of a hand into the containers where they have been placed.
3. Procedures involving the blood or other potentially infectious substances shall
be performed in a manner that minimizes splashing, spraying, spattering and the
generation of droplets of the substance.
4. Mouth pipetting or suctioning of blood or other potentially infectious
substances is strictly prohibited.
5. Specimens of blood or other potentially infectious substances shall be placed
in color-coded/ labeled and leak-proof containers for collection, handling,
storage, transport and shipment.
6. Broken glassware that may be contaminated with blood or other potentially
infectious substances must always be picked up by a mechanical means (e.g.,
brush, dust pan, tongs, forceps, etc.).
Version – February 2014
Page 3
LONGWOOD
Office of Environmental Health, Occupational Safety
& Emergency Management
UNIVERSITY
7. Employees must always wash their hands with an antiseptic cleanser
immediately after, or as soon as the event allows, removing gloves or other
personal protective equipment or any contact with blood or other potentially
infectious substances (hand-washing facilities are located throughout the
campus and antiseptic hand cleansers are maintained with exposure control
PPE).
8. Eating, drinking, smoking, applying cosmetics or lip balm or handling of
contact lenses is prohibited in areas where there is reasonable likelihood of
exposure to blood or other potentially infectious substances.
9. Food or beverages are not to be kept in refrigerators, freezers, shelves or
cabinets, or on counter or bench tops, where blood or other potentially
infectious substances are present.
Employee implementation and/or adherence to each of the above engineering or work control
practices shall be verified via a documented regular inspection of Longwood University first aid
or health care facilities and operations, where feasible, conducted by the Environmental Health
and Safety Officer.
c) Personal Protective Equipment (PPE)
Where engineering and work control practices fail to eliminate the potential for occupational
exposure to blood or other potentially infectious materials, Longwood University employees
shall utilize PPE to abate the remaining hazards.
PPE Selection & Use
PPE shall be selected based upon the anticipated means or method of exposure and will be
considered appropriate only if it does not allow blood or other potentially infectious substances
to pass through or reach the employees’ clothing or result in exposure under normal conditions
and duration of use.
Version – February 2014
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LONGWOOD
Office of Environmental Health, Occupational Safety
& Emergency Management
UNIVERSITY
The following table outlines specific types of potential exposure events and the corresponding
PPE necessary to eliminate or minimize the exposure hazard:
1.
2.
1.
2.
Exposure Hazard
Whenever it is reasonably
anticipated that hand
contact with blood, nonintact skin or organs,
mucous membranes, or
other potentially infectious
materials will occur.
When performing vascular
access procedures or
handling or touching
contaminated items or
surfaces.
Whenever it is reasonably
anticipated that face, eye,
nose, or mouth contact
with splashes, spray,
splatter, or droplets of
blood or other potentially
infectious materials will
occur
Whenever it is reasonably
anticipated gross
contamination of body or
cloths with blood or other
potentially infectious
materials will occur (e.g.,
autopsies, surgery,
amputations, etc.)
PPE
When Use Required
Disposable physician’s
examination / surgical or
general use utility gloves
During all general first aid or
health care assistance
activities
Goggles, safety glasses w/
side shields and/or chinlength face shield
During all first aid or health
care assistance activities
involving free-bleeding or
body fluids expulsion
Gown or Apron
During all first aid or health
care assistance activities
involving severed arteries,
severe lacerations or
amputations
NOTE: An exception to the mandatory use of PPE exists whenever it can be verified by a
member of management that an employee temporarily and briefly declined to use PPE
under rare and extraordinary circumstances in which was the employee’s professional
judgment that its use in the specific instance would have prevented the delivery of
health care or posed an increased hazard to the safety of the worker or co-worker.
Version – February 2014
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LONGWOOD
Office of Environmental Health, Occupational Safety
& Emergency Management
UNIVERSITY
PPE Availability
All required PPE shall be provided at no cost to affected Longwood University employees and
may be obtained from the Departmental Supervisor.
Sufficient sizes and quantity of the above listed PPE shall be maintained in the affected
departments at all times to outfit each employee that may be expected to incur an
occupational exposure while performing their assigned duties or responsibilities.
Hypoallergenic gloves, glove liners, powderless gloves, or other similar alternatives shall be
readily accessible to those employees who are allergic to the gloves normally provided.
The Environmental Health and Safety Officer shall inspect on a periodic basis the PPE inventory
at each of the indicated storage locations and shall ensure correction, within 72-hours, of any
deficiencies noted in the style, size, or quantity of PPE available.
PPE Cleaning, Laundering and Disposal
All re-usable PPE shall be cleaned and laundered, as well as repaired or replaced when
discovered to be defective, at no cost to affected Longwood University employees.
All garments that become saturated and/or penetrated by blood or other potentially infectious
substances must be removed immediately, or as soon as the incident allows, and prior to
leaving the immediate work or incident location. This procedure should be done in such a way
as to avoid contact with the outer surface.
All removed PPE shall be immediately, or as soon as the incident allows, placed into proper
containers, sealed and relocated to a designated location for storage prior to laundering,
decontamination, or disposal.
NOTES:
V.
1) Disposable examination or surgical gloves are not to be decontaminated for
re-use and must be discarded after each use event.
2) Reusable utility gloves may be decontaminated for re-use if their integrity is
not compromised (e.g., cracked, peeling, torn, punctured or showing other signs
of deterioration or inability to function as a barrier).
Sanitation
All work or general area surfaces shall be immediately, or as soon as the event allows,
decontaminated after completion of procedures or the spill of blood or other potentially
infectious substances. Contaminated surfaces shall also be decontaminated at the end of the
work shift if the surfaces may have become contaminated since the last cleaning.
Version – February 2014
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LONGWOOD
UNIVERSITY
Office of Environmental Health, Occupational Safety
& Emergency Management
All bins, pails, cans, boxes, or other containers utilized to store blood, other potentially
infectious substances, or regulated medical wastes shall be inspected on a regularly scheduled
basis by the Environmental Health and Safety Officer for the presence of exterior
contamination. Any container observed with exterior blood or other potentially infectious
substances shall be immediately decontaminated and over-packed if damaged or leaking.
The Director of Student Health shall ensure that any equipment in the Student Health and
Wellness Center that is possibly contaminated with blood or other potentially infectious
substances is examined, prior to servicing or off-site shipment, and that all suspect equipment
is decontaminated as necessary, unless decontamination is not physically possible. The
Environmental Health and Safety Officer will perform this duty in all other areas beyond the
Student Health and Wellness Center.
Decontamination of surfaces or equipment shall be achieved via the use of an EPA-registered
germicide or bleach and water mixture (1 part bleach to 10 parts water) and a brush, sponge, or
sanitary cloths or wipes. Decontamination supplies shall be maintained in each of the locations
utilized to house exposure control PPE. The Environmental Health and Safety Officer shall
inspect the decontamination supply inventory on a regular basis and ensure correction of any
observed decontamination supply deficiencies within 72-hours of the inspection.
VI.
Sharps & Regulated Waste Management
a) Sharps
Contaminated needles and other contaminated sharps (e.g., broken glass) may not be
purposely broken or sheared and must be placed in designated sharps containers maintained at
each of the locations utilized to house exposure control PPE.
Re-capping, bending, or removal of contaminated needles may take place only when required
by a medical procedure or no alternative is feasible. If this action is deemed necessary, it must
first be approved by a member of Longwood University management and then be conducted by
the use of a mechanical device or a one-handed technique. Currently there are no known
circumstances or first aid delivery practices existing at Longwood University requiring the
bending, re-capping or removal of contaminated needles or other contaminated sharps.
Immediately upon use, or as soon as feasible, contaminated disposable needles and other
sharps shall be placed in a closeable, puncture resistant, labeled / color-coded and leak-proof
container for storage prior to scheduled off-site shipment for disposal. During use and while in
storage, all sharps containers will be maintained in an upright position and not allowed to
overfill. Immediately prior to movement or transport, sharps containers shall be closed to
prevent spillage or protrusion.
Version – February 2014
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LONGWOOD
UNIVERSITY
Office of Environmental Health, Occupational Safety
& Emergency Management
The Environmental Health and Safety Officer shall inspect all locations where contaminated
disposable needles and sharps containers are housed on a regular basis. Any observed leakage
will be addressed by the Environmental Health and Safety Officer within 4-hours of the
inspection by placing the container in a closeable, labeled / color-coded, leak-proof secondary
container capable of holding the entire contents of the original.
b) Regulated Waste
Liquid or semi-solid blood or other potentially infectious materials, including items that could
release blood or other potentially infectious substances or that are caked with dried blood (e.g.,
bandages, wipes or gauze pads), must be placed immediately, or as soon as feasible, in a
closeable, labeled / color-coded and leak-proof container for storage prior to scheduled off-site
shipment for disposal. Immediately prior to movement or transport, regulated medical waste
containers shall be closed to prevent spillage or protrusion.
VII. Hepatitis B Vaccine & Post-Exposure Evaluation and Follow-Up
Longwood University shall make the hepatitis B vaccine and vaccination series available to all
employees who have occupational exposure, as well as provide a post-exposure evaluation to
all employees who have had an exposure incident.
Human Resources shall ensure that the above medical evaluations and procedures are made
available to affected employees at no cost, at a reasonable time and place, and are conducted
by or under the supervision of a licensed physician or other licensed health care professional.
a) Hepatitis B Vaccination
The hepatitis B vaccination shall be made available to an affected employee upon receipt of
occupational exposure training and within 10 working days of initial assignment to a job
classification identified to have occupational exposure to blood or other potentially infectious
substances.
NOTES:
1) The hepatitis B vaccination will not be made available to affected employees
when it can be documented that the employee has already received the
complete hepatitis B vaccination series, if antibody testing has revealed that the
employee is immune, or the vaccine is contraindicated for medical reasons.
2) Affected employee participation in a pre-screening program will not be a
prerequisite for receiving the hepatitis B vaccination.
Longwood University has selected a doctor to provide the hepatitis B vaccination to all affected
employees.
Version – February 2014
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LONGWOOD
UNIVERSITY
Office of Environmental Health, Occupational Safety
& Emergency Management
If an affected employee initially declines the hepatitis B vaccination but at a later date (while
still covered by the standard) decides to accept the vaccination, it will then be made available
within 10 working days of request. All affected employees who initially decline the hepatitis B
vaccination shall be required to sign a waiver indicating their refusal. (See Appendix C for
hepatitis B vaccination waiver form.)
In the event that a licensed physician or other licensed health care professional recommends a
booster dose of hepatitis B vaccine for an affected employee, it shall be provided within 10
working days of written receipt of the recommendation.
b) Post-Exposure Evaluation and Follow-Up
All Longwood University employees that have incurred an exposure incident shall be offered
post-exposure evaluation and follow-up at no cost.
All blood or other potentially infectious substances exposure incidents must be immediately, or
as soon as the incident allows, reported to the Environmental Health and Safety Officer for
documentation and investigation.
Following notification of an exposure event, the exposed employee must immediately, or as
soon as scheduling permits, receive a confidential medical evaluation and follow-up that
includes the following elements:
•
•
•
NOTES:
Documentation of the route of exposure and circumstances under which the
exposure incident occurred;
Identification and documentation of the source individual; and
Collection and testing of a sample of the exposed employee’s and source
individual’s blood as soon as feasible, upon consent receipt, to determine
bloodborne pathogens infectivity.
1) When documentation indicates that the source individual is infected with HBV or
HIV, blood testing for that individual’s known HBV or HIV status is not required.
2) If an exposed employee declines the option of blood collection and testing to
determine HBV and HIV serological status, a sample shall still be collected as soon as
possible and preserved for 90 days to allow the employee to determine if it should
be tested for infectivity status.
Results of the source individual’s testing or infectivity status shall be made available to the
exposed employee, along with information regarding the laws and regulations concerning
disclosure of the identity and infectious status of the source individual.
Longwood University has selected a doctor to provide post-exposure evaluation and follow-up
to affected employees. Human Resources shall provide the following information to the
Version – February 2014
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LONGWOOD
UNIVERSITY
Office of Environmental Health, Occupational Safety
& Emergency Management
licensed physician or other licensed health care professional conducting the hepatitis B
vaccination or post-exposure evaluation:
•
•
•
•
•
A copy of 29 CFR 1910.1030;
A written description of the exposed employee’s duties as they relate to the exposure
incident;
Written documentation of the routes of exposure and circumstances under which the
exposure occurred;
Results of the source individual’s blood testing (if available); and
All medicals records relevant to the appropriate treatment of the employee, including
vaccination status.
Human Resources shall obtain a written copy of the evaluating licensed physician’s or other
licensed health care professional’s written opinion within 15 days of completion of the
evaluation.
The licensed physician’s or other licensed health care professional’s written opinion for HBV
vaccination and post-exposure follow-up will be limited to the following information:
•
•
•
Whether vaccination is indicated for the exposed employee and whether the employee
has received the vaccination;
A statement that the employee has been informed of the results of the evaluation; and
A statement that the employee has been advised about any medical conditions resulting
from exposure to blood or other potentially infectious substances that require further
evaluation and/or treatment.
VIII. Warning Labels and Signs
The Environmental Health and Safety Officer shall ensure that biohazard labels are utilized in
the following instances or circumstances:
•
•
On all refrigerators and freezers containing blood or other infectious substances; and
When color-coded red bags or red containers are not utilized for the storage, transport
of shipment of blood, other potentially infectious substances or regulated waste.
NOTE: Containers of blood, blood components or blood products that are labeled as to their
contents and have been released for transfusion or other clinical use are exempted from
the labeling requirement.
Required labeling must be fluorescent orange or orange-red and include the universal
biohazard symbol and the legend BIOHAZARD. In the case of regulated medical waste, the
words BIOHAZARDOUS WASTE may be substituted for the BIOHAZARD legend.
Version – February 2014
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LONGWOOD
UNIVERSITY
IX.
Office of Environmental Health, Occupational Safety
& Emergency Management
Employee Information and Training
Prior to assuming a position where occupational exposure to blood or other potentially
infectious materials may be expected, new or transfer employees of Longwood University shall
attend a bloodborne pathogens exposure training session. The Environmental Health and
Safety Officer is responsible for organizing and ensuring that the stated training is conducted.
The training will consist of one (1) session lasting approximately forty-five (45) minutes.
The format for the initial training program will be:
•
•
•
Classroom instruction (20 minutes)
Audiovisual (10 minutes)
Comprehension quiz (15 minutes)
The following items shall be covered:
•
•
•
•
•
•
•
•
•
•
Review of 29 CFR 1910.30 and the location where it may be accessed;
Review of Longwood University’s Bloodborne Pathogens Exposure Control Plan;
Identification and discussion of pathogenic microorganisms;
Identification of tasks that may involve exposure;
Review of engineering and work practice controls, to include sanitation;
Identification of required PPE and its selection, use, location, removal, handling and
decontaminations requirements;
Discussion of hepatitis B vaccination, to include availability and effectiveness;
Review of exposure reporting and post-exposure and follow-up procedures;
Explanation of warning labels and signs, to include color-coded containers; and
Review of employee training requirements.
When there is a change in an employee’s job assignment or duties that affect their potential for
occupational exposure to blood or other potentially infectious substances, the Environmental
Health and Safety Officer, upon notification by a Department Supervisor or the Human
Resources Department, will organize and ensure that update bloodborne pathogens exposure
training is provided for the affected employee.
The Environmental Health and Safety Officer is responsible for organizing and ensuring that
bloodborne pathogens exposure refresher training is conducted annually for all affected
Longwood University employees.
Following each initial, update or refresher training session, all attending employees will be
required to sign and date a training attendance record.
Version – February 2014
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LONGWOOD
UNIVERSITY
X.
Office of Environmental Health, Occupational Safety
& Emergency Management
Recordkeeping
The Environmental Health and Safety Officer shall ensure that all records required under the
Bloodborne Pathogens standard are maintained in their designated locations and in their
entirety.
a) Medical Records
All medical records related to occupational exposure to blood or other potentially infectious
substances for affected employees shall be maintained in the Human Resources Department,
via the employee’s personnel file, for their period of employment, plus 30 years.
All medical records shall be maintained in a confidential manner and will not be disclosed
without the written approval of the affected employee. The following information shall be
included:
•
•
•
•
•
Employee’s name and social security number;
A copy of the employee’s HBV vaccination status, including dates of vaccination and
ability to receive vaccination;
A copy of all examination results, medical testing and follow-up procedures;
A copy of information provided to the health care professional, including a description
of the employee’s duties that relate to the exposure incident, and documentation of the
routes of exposure and circumstances of exposure; and
A confidential copy of the health care professional’s written opinion.
b) Training Records
All affected employee Bloodborne Pathogens Exposure Control Plan information and training
records shall be maintained in the Environmental Health and Safety Office for a period of 3
years from the date of the training.
Employee information and training records shall include the following:
•
•
•
•
Date of the training session;
An outline of the material presented;
Names and qualifications of the presenters; and
Names and job titles of all employees attending the training session.
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LONGWOOD
UNIVERSITY
Office of Environmental Health, Occupational Safety
& Emergency Management
c) Records Availability
Each affected employee’s medical and training records shall be made available for review
and/or copying within 15 working days of receipt of written access request.
d) Transfer of Records
Should the facility be closed or cease operations, the Environmental Health and Safety Officer
shall notify the Director of the National Institute of Occupational Safety and Health (NIOSH) at
least 3 months prior of the event and submit all records to the Director if so requested.
e) Sharps Injury Log
For cases that involve percutaneous injury from contaminated sharps, the Human Resource
Department is responsible for maintaining a Sharps Injury Log. Information shall be entered on
the log as to protect the confidentiality of the injured employee. At a minimum, log entries
shall document the following:
•
•
•
•
Date of Injury
Type and brand of the device involved (syringe, needle)
Department or work area where the incident occurred
Explanation of how the incident occurred
This log is reviewed as part of the annual program evaluation and maintained for at least five
years following the end of the calendar year covered. If a copy is requested by anyone, it must
have any personal identifiers removed from the report.
XI.
Plan Review
The Environmental Health and Safety Officer shall review the written Bloodborne Pathogens
Exposure Control Plan for Longwood University annually and modify the plan, or provide
additional employee training, if deficiencies in compliance with the standard or plan procedures
are identified.
Both front-line workers and management officials will evaluate new products and new
procedures, identify any need for changes in engineering controls and work practices, and
provide a proactive engagement with the EHS Officer throughout the year by completing an
Employee Safety Recommendation Form whenever a change can eliminate or reduce exposures
to bloodborne pathogens.
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LONGWOOD
Office of Environmental Health, Occupational Safety
& Emergency Management
UNIVERSITY
XII. Document History
Version
July 2003
February 2014
Date
07/28/2003
02/15/2014
Version – February 2014
Comments
Initial BBP Exposure Plan
Reviewed and Updated Plan
Page 14
LONGWOOD
UNIVERSITY
Office of Environmental Health, Occupational Safety
& Emergency Management
Appendix A – Category 1 – Job Classification
Expected to Incur Occupational Exposure
At Longwood University, the following job classifications have occupational exposure to blood
or other possibly infectious materials during certain tasks or procedures:
Job Classification
Police Sergeant
Police Investigator
Police Officer
Director of Student Health
Assistant Director of Student Health
Advanced Practice Clinicians
Trade Tech (Plumbers)
Head Athletic Trainer
Assistant Athletic Trainer
Aquatic & Fitness Instructor
Designated First Aid Responders
Registered Nurses
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LONGWOOD
UNIVERSITY
Office of Environmental Health, Occupational Safety
& Emergency Management
Appendix B – Category 2 – Job Classification
That May Incur Occupational Exposure
At Longwood University, the following job classifications may have occupational exposure to
blood or other possibly infectious materials during certain tasks or procedures:
Job Classification
Tasks/Duties
Trades Manager(s)
Routine duties where blood or OPIM may be
present
Emergency Response and routine duties
where blood or OPIM may be present
Emergency Response and routine duties
where blood or OPIM may be present
Routine duties where blood or OPIM may be
present
Administering First Aid and/or
treatment of athletic injury
Administering Basic First Aid or CPR
until responders arrive.
Administering Basic First Aid or CPR
until responders arrive.
Routine duties where blood or OPIM may be
present
Director of Public Safety
Environmental Health and Safety
Officer
Administrative Assistants (Student
Health & Counseling Center)
Sports Coach & Assistants
Residential Ed. Coordinator or
Residential Assistant
Area Coordinators and/or Floor
Wardens
Child Development Center
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LONGWOOD
Office of Environmental Health, Occupational Safety
& Emergency Management
UNIVERSITY
Appendix C – Sharps Injury Log
Coverage Period: January
Date
Date &
Entered Time of
Injury
Type &
Brand of
Device
to December
Department
or Work Area
that Injury
Occurred
Description of Incident
This form shall be retained in the Human Resources Department until
December
(Five years after the end of the Log Year)
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LONGWOOD
Office of Environmental Health, Occupational Safety
& Emergency Management
UNIVERSITY
Appendix D - Hepatitis B Vaccine Form
Instructions: Read the following information and CHOOSE ONE of the three options.
I understand that due to my occupational exposure to blood or other potentially infectious
materials I may be at risk of acquiring Hepatitis B virus (HBV) infection. I have been given the
opportunity to be vaccinated with Hepatitis B vaccine, at no charge to myself.
I understand that by declining this vaccine, I continue to be at risk of acquiring Hepatitis B, a
serious disease. If in the future I continue to have occupational exposure to blood or other
potentially infectious materials and I want to be vaccinated with Hepatitis B vaccine, I can
receive the vaccination series at no charge to me.
___
____
I do not want the Hepatitis B vaccination series at this time. I have read and
understand the above statement.
___
____
I have previously received the Hepatitis B vaccination series. Approx. dates ____
I understand that receiving the Hepatitis B vaccine imposes certain risks upon me as detailed in
the Bloodborne Pathogens training seminar. I voluntarily consent to such risks and agree to
hold the Longwood University harmless from any and all claims and causes of action for any
injury, loss, or damage resulting from such vaccination.
___
____
I do want the Hepatitis B vaccination series at this time. I have read and
understand the above statement.
This form shall be kept in the Employee’s file in the Human Resources Department
Name:
Date:
Signature:
Witness Name:
Witness Signature:
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LONGWOOD
Office of Environmental Health, Occupational Safety
& Emergency Management
UNIVERSITY
Appendix E – Employee Safety Recommendation Form
Department:
Date:
Identification of Safety or Health Hazard:
Suggestion for Elimination or Reduction of Safety or Health Hazard:
Do Not Write Below This Line
Date Received by EHS&EM Office:
Comments / Action Taken:
Reviewed by:
Name of Employee submitting form:
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