Human Resources Office - Abilene Christian University
Employment Policies and Procedures

Section 700: Safety and Health
TABLE OF CONTENTS

• 710. Accident/Injury Reporting
• 720. Hazard Communication Program
• 730. Blood-Borne Pathogens Exposure Control Plan

Policy No. 710
October 1, 1994
Reviewed July 2004

ACCIDENT/INJURY REPORTING

PURPOSE
To establish guidelines for reporting job-related accidents and injuries.

SCOPE
This policy applies to all employees at the university.

POLICY
An employee who incurs a job-related illness or injury is required to report immediately to his/her supervisor.

PROCEDURE
Reporting Injuries

Supervisor's Responsibilities:

1. Refer the injured employee to the Walk-In Clinic on Judge Ely, or the emergency room, depending on the extent of the injury.  Employees can use their own physician, but the physician needs to be on the workers' compensation list of physicians or treatment will not be covered.
2. The employee/supervisor will email workinjury@acu.edu and then complete the form that is emailed back.  The form will then be faxed or mailed to Administrative Services.
3. The supervisor will contact the Safety Director who will investigate the cause of the incident to determine corrective action to be taken.
4. The Safety Director will prepare a written report giving details and circumstances surrounding the injury of illness (Report of Injury) after questioning the employee and all witness regarding the cause and circumstances of the injury.

Administrative Services/Case Manager Responsibilities:

Upon notification of a work-related injury or illness, the Administrative Services representative will:

1. Review the report and discuss the case with the Safety Director and they physician or person providing first aid or medical care to the employee.
2. Complete and process all necessary documents as required by the state and the workers' compensation insurance carrier; ensure that the employee receives the necessary medical treatment and that all claims and payments are handled promptly and efficiently.
3. Notify the injured employee that the Safety Director will contact the employee and complete an investigation of the accident and a representative from ACU's workers' compensation insurance carrier will then contact the employee for additional information.  The representative also will notify the employee of any further process if the employee is unable to return to work.
   
   If the injured employee is unable to work, the Administrative Services representative will contact the employee by phone once a week to communicate updates and get progress reports from employee.
   
   If the situation necessitates case management, a three-point assessment (supervisor, injured employee, physician) will be provided to determine treatment plan, obtain projected return to work (RTW) date to original position, determine restrictions and limitations during recovery period, and discuss early RTW positions available.

PURPOSE OF CASE MANAGEMENT

1. Begin steering the case to early return to work program in the same or modified alternative position.
2. Act as liaison between employee, claims and physician to prevent communication confusion.
3. Make sure physician has job description of present position, obtain consent for employees to return to this position, obtain treatment plan, date of release, release to modified position by presenting or alternate duty job description, by obtaining restrictions.
4. Work closely with supervisor of employees to advise of restrictions, to work within these restrictions, and to monitor compliance, success, results, progress, etc.
5. Follow up with physician regarding upgrading of activities and to encourage continuous progression of activities.

Light Duty Program

The health and well-being of every employee is of vital importance.  The active participation of Abilene Christian University and all its employees is necessary to make occupational health and safety programs of this type a success.  The primary goal is to decrease the number of safety and health-related accidents, injuries and losses.

The Safety Director will work closely with employees through appropriate channels to develop more effective and efficient programs.  The alternate duty program is designed to discover better ways to protect the safety and promote the health of employees that have been injured on the job.  Abilene Christian University fully recognizes the economic impact of health and safety policies.  It's believed that an alternate duty program of this type will improve overall health and safety records while promoting improved earnings.

It is the responsibility of each department head to provide the Director of Human Resources with jobs or functions within the department which can be performed by a person with some degree of work-related disability when a departmental employee has been injured.  It is the responsibility of the Director of Human Resources working with the employees' immediate supervisor and with the supervisor of the department in which work is to be performed, to arrange such assignments.

Recommended Rules to Follow:

• Create alternative duty positions.
• Don't make the position a promotion.
• Limit the time the alternative duty is available -- this is a temporary position (30-60 days)
• Don't make the position always easy -- tasks must get progressively harder.
• The jobs can be non-strenuous and limited, but shouldn't be pleasant or a holiday.
• Realize that every case is different, and every case may not be successful.
• Educate employees to the return to work (RTW) program as part of a benefit package.
• Educate physicians to your program, function and objections.  Prepare them how to work within your program.

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Policy No. 720
January 1, 1994
Reviewed July 2004

HAZARD COMMUNICATION PROGRAM

PURPOSE
To guard the health and safety of all employees by providing access to information regarding hazardous chemicals which they may be exposed to during normal employment activities and/or emergency situations.

PROCEDURE

Container Labeling

It is the policy of ACU that no container of hazardous substance to received or released for use until the following label information is verified:

• Container content clearly labeled
• Appropriate hazard warnings are noted
• Name and address of manufacturer are listed

Material Safety Data Sheets (MSDS)

• Every chemical and manufacturer or distributor must provide MSDS with initial shipment(s) of hazardous material(s) covered under the scope of the Hazard Communication Act.  These data sheets will be maintained on file and readily accessible to any employee in the work place.  Copies will be kept on file in the Safety Office and individual work areas.
• Each supervisor will review incoming data sheets for new and significant health/safety information and are responsible for communicating any new information to employees affected.
• MSDS will be reviewed for supervisors to ensure all are complete.  If a MSDS is missing or obviously incomplete, the Safety Director will request a replacement from the manufacturer.  MSDS are available in all work areas for any employee to review during all work shifts.

Employee Information and Training

Employees will be provided sufficient information and training to enable them to know the following:

• Requirements of the "Right-To-Know-Law"
• Operation where exposure is, or may be, present
• Location of:
  • Written hazard communication program
  • List of hazardous materials
  • Material Safety Data Sheets

Required training is defined as: Training necessary to enable an employee to perform assigned responsibilities in an informed manner so neither the employee nor fellow worker(s) are in danger.  Records of this training will become part of the permanent file maintained in the Safety Office for a period of thirty (30) years.

Mandatory annual refresher safety training will be organized by the Safety Director and must be attended by all personnel exposed to hazardous or potentially hazardous situations.

A notice will be posted in a prominent location in each department describing employee rights under the Right-To-Know-Law.

Hazardous Chemical Inventory

• A list of all hazardous chemicals known to be in the work place will be prepared.  "Hazardous Chemical" is defined as any element, chemical compound, or mixture of elements and/or compounds which is a physical or health hazard.
• A chemical list will be compiled for every work area in each department and will contain the following information:
  • Common Name
  • Chemical Name
  • Category (Acid, Base, Solvent)
  • Use
  • Safety equipment required and location
  • Quantity

This list will be updated as new hazardous chemicals are incorporated into the work pace.  A complete list will be made available to all personnel using these chemicals.

Reporting Requirements for Hazardous Chemicals

Each department will be responsible for compiling and maintaining a Workplace Chemical List.  this list will contain information for each hazardous chemical normally used or stored in the workplace in excess of 55 gallons, 500 pounds or of the Threshold Planning Quantity (TPQ) for chemicals found on the list of 366 Extremely Hazardous Substances (EHS).  It represents the priority chemicals of the emergency planning effort of the Superfund Amendment and Reauthorization Act (SARA), Title III Law and should contain the following information.

1. Chemical Name
2. Case Number
3. Quantity

This information will be reported to the Safety Director by department.  The information will be consolidated and reported via the Safety Director who will make the appropriate reports of these chemicals to the state.  This must be updated annually and kept on file for thirty (30) years.

Hazardous Substances in Unlabeled Pipes

To ensure that employees who work on or around unlabeled pipes have been informed of the hazardous substances contained within, the following procedure must be followed:

Prior to implementing work on or around unlabeled pipes, employees are to contact their supervisor for the following information:

• The hazardous substances in pipes
• Potential hazards
• Safety precautions which should be taken

Department heads and supervisors are responsible for ensuring that all provisions of the Hazard Communication Program are met in their area(s) of responsibility.  Each area will be audited by the Safety Director to determine compliance with the law and existing University policy on hazardous chemicals.

Accountability

Supervisors are responsible for:

• Ensuring compliance with the provisions outlined in this policy.
• Review of the Hazardous Communication Training Program for accuracy and compliance prior to annual training.
• Providing an annual report to the Safety Director for compilation and forwarding to Environmental Health Safety.

Supervisors are Responsible for:

• Identifying chemicals used in assigned work area(s).  Ensuring all chemicals are properly labeled.
• Maintaining MSDS for their individual area(s) and advising the Safety Director of those chemicals which require a MSDS.
• Developing a Hazardous Chemical Inventory for their individual area(s) and provide the Safety Director all updated information of additions/deletions so appropriate records may be kept current.
• When a new chemical is introduced in the work area, providing MSDS training to all employees affected, completing the training sheet, and sending original training documentation to the Safety Director to remain on permanent file for thirty (30) years.
• Training all employees on the proper use of chemicals and related safety equipment prior to allowing them to perform their normal duties.  Supervise them to ensure compliance.
• Continuously monitoring the work area for proper techniques and use of safety equipment.

The Safety Director is Responsible for:

Maintaining a Hazard Communication Act bulletin board with the following items posted:

• "Notice to Employees"
• Action for Chemical Emergencies and MSDS locations
• "What You Know"
• "Hazardous Chemical Inventory"
• Hazard Identification Checklist

Supervisor or person ordering chemicals should request a MSDS at the time of ordering.  Retailers and wholesalers are bound by the law to furnish a MSDS upon request of the customer.

Initiating and providing appropriate paperwork to supervisors for annual training.

Employees are Responsible for:

• Being continuously alert to the very real hazards of substances used on the job.
• Alerting the supervisor of Safety Director immediately of any problem associated with hazardous substances, to include at least the following:
  • Spill(s) or contact with hazardous substances
  • Presence of an unidentified substance (to be treated as hazardous until verified otherwise)
  • Any need for additional safety equipment or revised procedures.
• Having a "working knowledge" of the information posted on the department's Hazardous Substances bulletin board, with particular emphases on the Chemical Emergency Sheet.
• Initiating and providing appropriate paperwork to departments for chemical reporting under SARA, Title III.  Preparing consolidated report for Environmental Health and Safety.
• Understanding the proper use of procedures and safety equipment.

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Policy No. 730
January 1, 1994
Reviewed July 2004

BLOOD-BORNE PATHOGENS EXPOSURE CONTROL PLAN

PURPOSE
To reduce exposure and the potential for disease to employees occupationally at risk for contact with blood and other potentially infectious materials.

SCOPE
This policy applies to those who have duties or responsibilities to perform tasks and procedures where occupational exposure occurs such as nurses, athletic trainers, intramural director, food preparers, and Human Performance Lab assistants.  It also applies to positions who may periodically have the potential for occupational exposure such as campus police.

POLICY
This exposure control plan is accessible to all employees and will be reviewed at least annually and updated as often as changes in positions, tasks or procedures require.  This plan is located in the Medical Clinic for ease of accessibility for all employees.

Methods of compliance are various strategies, practices, and/or protocols developed by the university based on present literature to minimize or remove the potential for exposure to employees.

DEFINITIONS

1. Blood-home Pathogen.  A bacteria or virus that can cause disease and can be transmitted from one person to another through the blood or other body fluid.  These pathogens include, but are not limited to, Hepatitis B Virus (HBV) and Human Immunodeficiency Virus (HIV).  Malaria, syphilis and brucellosis are other diseases resulting from exposure to blood-borne pathogens.
2. Contaminated Sharps.  Any contaminated object that can penetrate the skin including, but not limited to, needles, scalpels, broken glass, broken capillary tubes and lancets.
3. Hepatitis B (HBV).  A viral infection of the liver which is transmitted through the blood of the infected person (either chronic carriers or those in an acute stage).  Infection is usually most severe in adults and less severe in children.  The results of Hepatitis B infection may include: liver failure, cirrhosis, chronic hepatitis and liver cancer.
4. Exposure Incident.  A specific eye, mouth, other mucous membranes, non-intact skin or parenteral contact with blood or other potentially infectious materials that results from the performance of an employee's duties.

PROCEDURE
Since it is possible to become infected through a single exposure, opportunities for exposure must be prevented to the greatest degree possible.  Employees who can reasonably expected exposure to blood-home pathogens must adopt Universal Precautions as an infection-control method.  This implies that all human blood and other potentially infectious materials (such as body fluids and human tissues) will be treated as though they were known to be infectious.

Personal protective equipment (PPE) will be provided by the department.  The selection of protective equipment depends on the nature of the exposure, but generally includes latex gloves, and may include lab coats, gowns and goggles.

1. Employees MUST use appropriate PPE whenever there is potential occupational exposure.
2. Gloves must be worn whenever hand contact with blood or other potentially infectious materials, mucous membranes or non-intact skin can reasonable be anticipated.  Gloves must be worn when touching contaminated items or surfaces.
3. Disposable (single-use) gloves, such as surgical or exam gloves, must be replaced as soon as practical when they become contaminated or as soon as feasible if they are torn or punctured or their ability to function as a barrier is compromised.
4. Disposable (single-use) gloves should NEVER be reused.
5. Utility gloves may be decontaminated for resuse as long as the integrity of the gloves is not compromised.  However, they must be discarded if they become cracked or torn or show any other sign that their ability to function as a barrier is compromised.
6. Contaminated disposable PPE is discarded into a Medical Waste Disposal System established by each department and removed on an as needed basis.
7. Sharps containers are located in patient care areas.  Containers are puncture resistant, labeled, leak-proof on the sides of the bottom, closeable, and translucent.  Needle disposal units are checked daily and properly disposed of as needed.
8. Contaminated needles and other contaminated sharps are not recapped or removed unless NO other alternatives is feasible.
9. Reusable sharps (scissors, tweezers) are placed in appropriate containers until they are decontaminated for reuse.
10. Hand washing facilities are readily accessible to employees in appropriate places.
11. Employees must wash their hands immediately or as soon as feasible after removing gloves or other personal protective equipment.
12. Employees must wash their hands and any other skin with soap and water, and flush mucous membranes (eyes, nose, mouth) and water, immediately or as soon as feasible after contact with blood or other potentially infectious materials.
13. Employees will be provided with antiseptic hand cleaner and towels if hand washing facilities are not feasible.
14. If sink or running water is not immediately available, an antiseptic hand cleaner in conjunction with clean cloth/paper towels or antiseptic towelettes can be used.  The product utilized is Purell Brand Instant Hand Sanitizer.
15. Eating, drinking, applying cosmetics or lip balm, and handling contact lenses is prohibited in any work area where there is a reasonable likelihood of occupational exposure.
16. 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.
17. All procedures involving blood or other potentially infectious materials are performed in such a manner so as to minimize aerosolization, splashing, spraying, spattering or generation of droplets.
18. Mouth pipetting/suctioning of blood or other potentially infectious materials is strictly forbidden.
19. All work sites are maintained in a clean and sanitary condition.  Regular cleaning is provided in each department.  Specific methods for cleaning environmental surfaces contaminated with potentially infectious material will be kept by the department responsible for decontamination.
20. All equipment and environmental and work surfaces must be cleaned and decontaminated after contact with blood or potentially infectious materials
21. All receptacles (reusable) which have a reasonable likelihood for becoming contaminated with blood or other potentially infectious materials are inspected and decontaminated on an as needed basis.  PPE will be worn and employees will not place hands into full receptacles to retrieve material.
22. Spills of blood or other potentially infectious materials will be wiped up immediately, or as soon as feasible, and the areas decontaminated with appropriate disinfectant.
23. Employees will wear utility gloves when cleaning contaminated equipment and surfaces.
24. Employees will use mechanical means to pick up broken glassware that may be contaminated.  Broken contaminated glassware may never be picked up by hand, even if gloves are used.
25. Disposal of all regulated medical waste shall be in accordance with applicable local, state and federal regulations.  B&E Environmental Systems, Inc. is the agency utilized by Health Services to remove medical waste from the office.
26. Hepatitis B vaccine and vaccination series will be provided free of charge to all employees identified as having occupational exposure, unless:
    1. the employee previously received the complete vaccination series
    2. testing reveals the employee is already immune
    3. the vaccine is contraindicated for medical reasons
    4. the employee chooses not to be vaccinated

The first dose of the vaccine should be administered within 10 working days of the employee's assignment to a job involving occupational exposure.  Before the vaccine is made available, the employee will receive training about the efficacy, safety, method of administration and benefits of vaccination.

Vaccination is performed under the supervision of a licensed physician or under the supervision of another healthcare professional.  Hepatitis B vaccine is provided according to the recommendations of the U.S. Department of Health and Human Services Immunization Practices Advisory Committee.

An employee is entitled to refuse vaccination, but the employee MUST sign a Hepatitis B Vaccine Declination form.  This is not optional.  An employee who initially declines to be vaccinated may elect to be vaccinated later at no cost to the employee.

Employees are to report all exposure incidents as defined in Section IV Definition D.  If exposure is questionable, inform your immediate supervisor for further direction.  When an exposure incident occurs, employees are to determine extent of injury and obtain first aid.  Steps necessary to care for the area that is exposed should be taken immediately.  A written accident/exposure incident form shall be completed with the following information:

1. Description of exposure and how it occurred
2. Identification and documentation of source individual if possible
3. Collection of blood for HIV/HBV testing if indicated

Upon obtaining consent, an exposed individual's blood will be collected and tested for HIV and HBV as soon as feasible.  An employee may consent to have blood drawn but does not have to give consent for a HIV test.  Blood shall be held for a period of 90 days by the testing facility.  If the employee chooses to have the HIV test performed within 90 days, the initial specimen collected is used.  Otherwise, the laboratory may discard the sample after 90 days.

EMPLOYEE REFUSAL FOR HIV AND HBV TESTING IS DOCUMENTED AND FILED IN THE EMPLOYEE'S RECORD.

The employee will be provided with the following:

1. Post-exposure prophyaxis, when medically indicated
2. Counseling
3. An evaluation of (potential) reported illnesses.  This benefits the employee by providing the most up-to-date information available regarding potential illnesses.  In turn, the employee will have the benefit of early medical evaluation of such illnesses and receive current recommended treatment.  This facility utilizes an internal employee health department to perform Hepatitis B vaccination and post-exposure follow-up.  The above listed healthcare professional (HCP) has a copy of the "Blood borne Pathogen Standard" provided by this facility.  The HCP receives a copy of the exposure incident report.  The HCP receives a copy of the source individuals blood test, if available, and are kept confidential.  The HCP receives or has all medical records maintained by the employer relevant to the appropriate treatment of the exposed employee, including vaccination status.

LABELS
Potentially bio hazardous materials are color-coded red or identified with the biohazard symbol and the word "BIOHAZARD" in contrasting color on a fluorescent orange or orange-red label.

MEDICAL RECORDS
A confidential medical record is maintained for each employee with occupational exposure.  The medical record includes:

1. Name and social security number
2. Hepatitis B immunization status (dates) and any of the following that apply:
   1. Exposure incident report
   2. Written opinion of healthcare professional
   3. Form refusing Hepatitis B vaccination
   4. Form refusing post-exposure evaluation and follow-up

Employee medical records are maintained in the Health Services Office.  Employee medical records are kept confidential and will not be disclosed without the employee's consent or as required by law.  Employee medical records are retained for the length of employment plus 30 years.

TRAINING
All employees will be provided with training before they being work involving occupational exposure.  Thereafter, training will be provided at least annually and whenever changes in tasks or procedures require.  Training will be provided during work hours at no cost to the employee by someone who is familiar with the standard as it relates to the occupational hazard.  Training will include:

• An explanation of the Blood borne Pathogens Standard and where a copy of the standard is filed.
• General information about the epidemiolgy and symptoms of blood borne diseases.
• Modes of transmission of blood borne pathogens.
• An explanation of the exposure control plan and how to obtain it.
• How to recognize tasks involving occupational exposure.
• The use and limits of engineering controls, work practice controls and personal protective equipment (PPE).
• Where PPE is located and how to use, remove, handle, decontaminate and dispose of it.
• How to select appropriate PPE.
• The effectiveness, safety, benefits and method of administering Hepatitis B vaccine and that vaccination will be provided free of charge.
• What to do if there is an emergency spill of blood or other potentially infectious material.
• What to do if an exposure incident occurs.
• Post-exposure evaluation and follow-up that will be made available to employees in case of an exposure incident.
• The system of labels and color-coding used to warn of biohazards.
• An opportunity for interactive questions and answers.

The employer will maintain a record of all training sessions.  The training record will include:

1. Date of training
2. Contents of training (a summary of list of subjects)
3. Name and qualification of trainer
4. Name and job title of each person attending

Training records are kept in the ACU Medical Clinic.

Training records are retained for 3 years following the training session.  Employees may inspect training records or obtain a copy by contacting the ACU Medical Clinic.

Any employee who has a question about this exposure control plan or how it is implemented in this facility is encouraged to contact the ACU Medical Clinic for more information.

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