Form A: Annual Review

ANNUAL REVIEW - Form A

The Exposure Control Plan is to be reviewed annually. The review and update are required to reflect changes in technology that eliminate or reduce exposure to bloodborne pathogens.

Review Date

Exposure Control Plan Manager

Names of Employees Participating:

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The following commercial medical devices that eliminate or minimize occupational exposure were considered.

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Form B: All Employees

JOB CLASSIFICATIONS IN WHICH SOME EMPLOYEES HAVE EXPOSURE TO BLOODBORNE PATHOGENS

Below are listed the job classifications in our school district where some employees handle human blood, body fluids, and other potentially infectious materials which may result in possible exposure to bloodborne pathogens:

Form C: Some Employees

WORK ACTIVITIES INVOLVING POTENTIAL EXPOSURE TO BLOODBORNE PATHOGENS

Below are listed the tasks and procedures in our school district where some employees handle human blood, body fluids, and other potentially infectious materials which may result in possible exposure to bloodborne pathogens:

TASK/PROCEDURE JOB TITLE DEPARTMENT/LOCATION

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Form E: Sharps Injury Log

SHARPS INJURY LOG

DATE	DEVICE TYPE	DEVICE BRAND	DEPARTMENT	HOW DID INJURY OCCUR?

Form F: Engineering Control Equipment

ENGINEERING CONTROL EQUIPMENT

The following areas have, or should have, engineering control equipment to eliminate or minimize employee exposure to bloodborne pathogens. If equipment is needed but not yet installed, "NONE" is indicated in the Control Equipment column.

DEPT/LOC	CONTROL EQUIPMENT	NEED UPDATE?	LAST REVIEW DATE

Form G: Informed Consent

Confidential

INFORMED CONSENT FOR HEPATITIS B VACCINATION

(For employees and independent contractors)

I, __________________________________, hereby authorize my employer to vaccinate me against Hepatitis B virus (HBV). I understand that the injections are given over a period of several months before it is effective in preventing this disease.

I have been informed of occasional side effects resulting from HBV immunization which include, but are not limited to, pain, itching, bruising at the injection site, sweating, weakness, chills, blushing and tingling, as well as other side effects, warnings and contraindications noted in The Physician's Desk Reference and manufacturer's information sheets.

I have been informed that hypersensitivity to yeast is a contraindication for use of the vaccine; that the vaccine should be administered to a pregnant woman only if clearly needed, and to nursing mothers with caution.

All my questions have been answered to my satisfaction. I believe that I have adequate knowledge upon which to base an informed consent to the vaccination. I acknowledge that no guarantees have been made to me concerning the results of the proposed vaccination. I hereby release my employer from any and all liabilities and legal responsibilities as a consequence of my decision to receive this vaccine.

I have contacted my personal physician and he/she has given me permission to receive the vaccine, based on my previous medical history.

Signature __________________________________________

Date___________

Program Coordinator's Notation:

This employee has agreed to receive vaccination against Hepatitis B. The vaccination series will be provided at no cost to the employee by this educational facility.

Signature of Program Coordinator_____________________ Date _______

Note: Maintain this record for the duration of employment plus 30 years.

Form H: Physician Approval

PHYSICIAN APPROVAL

I authorize (school district) to immunize (employee) against Hepatitis B.

Physician Signature

Date

Form I: Vaccination Declination

INFORMED REFUSAL FOR HEPATITIS B VACCINATION

Employee Name _______________________________________

Job Title _____________________________________________

Social Security Number __________________________________

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. However, I decline the Hepatitis B vaccination at this time. 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.

Employee Signature

Date

Address

City State Zip

Form J: Exposure Incident Investigation Report

EXPOSURE INCIDENT INVESTIGATION FORM

Employee Name Address

Date of Incident Time of Incident

Location ______

Potentially Infectious Materials Involved

Type ___ Source ______

Circumstances (work being performed, etc.)
____________ _

_____________________________________________________________ __

How Incident Was Caused (accident, equipment malfunction, etc.)
_____________________________________

_

Personal Equipment Being Used
_____________

Actions Taken (decontamination, clean-up, reporting, etc.)
_______________________________

Recommendations for Avoiding Repetition ____________ ______

__________________________________________________________________

Signature of Employee ____ Date_ ______

Signature of Exposure Control Plan Administrator
___________ _____________

Date of Review

Form K: Exposure Incident Follow-up

EXPOSURE INCIDENT FOLLOW-UP

Exposure incident Date

Exposure Incident Form Completed Date

Exposure incident reported to supervisor Date

Medical evaluation Date

Information sent to health care professional Date

Copy of ( school district’s ) Exposure Control Plan
Employee's job description
Description of exposure incident (FORM J)
Results of source individual's blood tests (if known)
Employee immunization status (FORM N)

Source individual medical tests completed Date

Employee medical tests completed Date

Written report from health care professional Date

Hepatitis B vaccine given Date

Exposure incident reviewed Date

Form L: Refusal of Post-Exposure Follow-up

EMPLOYEE INFORMED REFUSAL OF POST-EXPOSURE MEDICAL EVALUATION

I, , am employed by ( school district ) . My employer has provided me training in bloodborne pathogens policies and the risk of disease transmission in the school. On (date) , 20 , I was involved in an exposure incident when I (describe incident)

.

My employer has offered to provide follow-up medical evaluation for me in order to assure that I have full knowledge of whether I have been exposed to or contacted an infectious disease from this incident.

However, I, of my own free will and volition, and despite my employer's offer, have elected not to have a medical evaluation. I have personal reasons for making this decision.

Signature

Witness

Name

Address

City, State, Zip

Date

Note: Maintain this record for the duration of employment plus 30 years.

Form M: Written Report From Physician

WRITTEN REPORT FROM PHYSICIAN

*****DUE BACK TO (SCHOOL DISTRICT) WITHIN 15 DAYS*****

Please check

Hepatitis B vaccination is indicated for the employee.

The employee has received the Hepatitis B vaccination.

The employee has been informed of the results of the
evaluation.

The employee has been told about any medical conditions
resulting from the exposure incident, which require further
evaluation or treatment.

Physician Signature
Date __

Form N: Employee Medical Record

EMPLOYEE MEDICAL RECORD FORM OF VACCINATION AND EXPOSURE INCIDENTS

Employee Name

Employee Address

Employee Social Security Number

Employee starting date

Employee termination date (if any) ___________

History of HBV vaccination (date received or, if not received, a brief explanation of

why not)

Results of medical follow-up procedures regarding exposure incidents

Date Name of Physician Seen Written Report Received from Physician

*Release of information required before sending to physician