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  Risk Management

Risk Management
 
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Environmental Health and Safety

 

Hazmat Information

 

Blood Borne Pathogen Exposure Plan

 

Please click on one of the links below for more information:

 

Blood Borne Pathogen Exposure Plan

  1. Introduction

  2. Management Commitment

  3. Exposure Determination (Scope & Application)

  4. Methods of Compliance

  5. Vaccination Against Blood Borne Pathogens

  6. Post Exposure Evaluations and Follow-up

  7. Communication Of Hazards To Employees (Training)

  8. Recordkeeping

  9. Appendix

  10. Glossary

 

IX.  APPENDIX

 

  1. Cal-OSHA General Safety Orders 5193

  2. Hepatitis B Vaccination Form

  3. Medical Evaluation Consent Form

  4. First Aid Incident Report Form

  5. First Aid Incident Report Log Form

  6. Biomedical Waste Suppliers List

  7. List of Educational Materials

  8. Hepatitis B Immunization Log

  9. Procedures for Handling Human Blood in Biology Labs

  10. Red Bag Label Master

  11. Procedures for Handling Human Blood in AOJ Labs

  12. List of locations of copies of the Exposure Control Plan

  13. Related G-CCCD Governing Board Policies

  14. Proposed Agreement to Provide HIV Testing, November 1996

  15. Health Sciences Instructor Training

APPENDIX A

GENERAL INDUSTRY SAFETY ORDERS
SECTION 5193

 

APPENDIX B

HEPATITIS B VACCINATION FORM

A. Declination:

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

Name:
Signature
Date:

 

2. I have been previously immunized for hepatitis B (HBV) and do not require additional vaccination.

Name:
Signature
Date:

 

3. I have been tested for hepatitis B (HBV) and have been shown to be immune.

Name:
Signature:
Date:

 

4. I decline hepatitis B (HBV) vaccine due to medical reasons.

Name:
Signature:
Date:

 

B. Acceptance:

1. I accept my employer offer for the hepatitis B (HBV) vaccination.
Name:
Signature:
Date:

 

 

APPENDIX C

MEDICAL EVALUATION CONSENT FORM
 

A. I consent to have both a baseline blood sample collection and serological testing of the sample.

Name
Signature:
Date:

 

B. I consent to allowing a baseline blood sample collection, but NOT to serological testing at this time. I understand the blood sample will be preserved for at least 90 days. I can request a serological test of the sample at any time within the 90 day period, but understand I must give an additional blood sample to document seroconversion.

Name:
Signature:
Date:

 

C. I do not consent to either a baseline blood sample collection or serological testing.

Name
Signature:
Date:

:

SOURCE INDIVIDUAL TESTING

Circle one of the following:

A. Source has agreed to testing.

B. Source has refused to be tested.

C. Source cannot be found or identified.

Name:
Signature:
Date:

 

 

 

APPENDIX D

FIRST AID INCIDENT REPORT
 

DATE: TIME:
NAME(S) OF RESPONDER(S)

 

 

 

 

 EXPOSURE INCIDENT? (Y/N)

 

 

 

 
INCIDENT DESCRIPTION :

 

 

 

 

 

 

 

 
Attach additional pages as necessary

 

APPENDIX E

FIRST AID INCIDENT
REPORT LOG

INCIDENT NUMBER

DATE

TIME

EMPLOYEE NAME(S)*

LOCATION OF
INCIDENT
         
         
         
         
         
         
         
         
         
         
         
         
         
         
         
         
         
         
         
         
         
         
         

 

 

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