Employee Handbook

Human Resources Office - Abilene Christian University 
Employment Policies and Procedures

Section 700: Safety and Health
TABLE OF CONTENTS

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 Dr. J Express Care, 1634 State Highway 351 Abilene, TX 79601, 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 risk@acu.edu and then complete the form that is emailed back.  The form will then be faxed or mailed to Office of Risk Management.
  3. The supervisor will contact the Safety Manager who will investigate the cause of the incident to determine corrective action to be taken.
  4. The Safety Manager 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.

Risk Management/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 Manager 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 Manager 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 Risk Management 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 Manager 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: March 1, 2011

HAZARD COMMUNICATION POLICY

Responsible Department: Office of Risk Management   
Responsible Administrator: Safety Manager

I. PURPOSE
Abilene Christian University has a commitment to provide each of its Employees a safe and healthy work environment. The purpose of this policy is to ensure that all Hazardous Chemicals used or produced on campus are evaluated and that the information concerning the hazard(s) is transmitted to employers and Employees in compliance with the Occupational Safety and Health Administration’s (OSHA) 29 CFR 1910.1200 Hazard Communication Standard and the State of Texas Hazard Communication Act Sec. 502.001.

II. SCOPE
This Hazard Communication Policy has been developed by the University to ensure that all Employees receive consistent and accurate information about the hazardous substances they work with or near on the campus. “This transmittal of information is to be accomplished by means of comprehensive hazard communication programs, which are to include Container Labeling and other forms of warning, Material Safety Data Sheets and Employee training.” 1910.1200(a)(1), Written Hazard Communication Program 1910.1200(e)   

III. DEFINITIONS

A. Chemical is defined as any element, Chemical compound or Mixture of element and/or compounds.  

B. Chemical Name is the scientific designation of a Chemical in accordance with the nomenclature system developed by the International Union of Pure and Applied Chemistry (IUPAC) or the Chemistry Abstracts Service (CAS) rules of nomenclature, or a name which will clearly identify the Chemical for the purpose of conducting a hazard evaluation.  

C. Combustible Liquid is any liquid having a Flashpoint at or above 100 0F (37.8 0C) but below 200 0F (93.3 0C), except any Mixture having components with Flashpoints of 200 0F (93.30 C), or higher, the total volume of which make up 99 percent or more of the total volume of the Mixture.

D. Compressed Gas is a gas or Mixture having, in a Container, an absolute pressure exceeding 40 psi at 70 0F (21.1 0C); or a gas or Mixture of gases having, in a Container, an absolute pressure exceeding 104 psi at 130 0F (54.4 0C) regardless of the pressure at 70 0F (21.1 0C); or a liquid having a vapor pressure exceeding 40 psi at 100 0F (37.8 0C) as determined by ASTM D-323-72.

E. Container is defined as any bag, barrel, bottle, box, can, cylinder, drum, reaction vessel, storage tank, or the like that contains a Hazardous Chemical. For purposes of this section, pipes or piping systems and engines, fuel tanks, or other operating systems in a vehicle, are not considered to be Containers.

F. Employee is defined as any individual currently classified as an Employee by Human Resources and/or currently on the University payroll who may be Exposed to Hazardous Chemicals under normal operating conditions or in Foreseeable Emergencies.    

G. Explosive is a Chemical that causes a sudden, almost instantaneous release of pressure, gas, and heat when subjected to sudden shock, pressure, or high temperature.

H. Exposure or Exposed is a condition under which an Employee is subjected in the course of employment to a Chemical that is a Physical or Health Hazard, and includes potential (e.g. accidental or possible) Exposure. “Subjected” in terms of Health Hazards includes any route of entry (e.g. inhalation, ingestion, skin contact or absorption.)

I. Flammable is a Chemical that is capable of burning or easily igniting and falls into one of the following categories:

1. Aerosol, Flammable is an aerosol that, when tested by the method described in 16 CFR 1500.45 yields a flame projection exceeding 18 inches at full valve opening, or a flashback (a flame extending back to the valve) at any degree of valve opening.

2. Gas, Flammable is a gas that: at ambient temperature and pressure, forms a Flammable Mixture with air at a concentration of thirteen (13) percent by volume or less; or a gas that, at ambient temperature and pressure, forms a range of Flammable Mixtures with air wider than twelve (12) percent by volume, regardless of the lower limit.

3. Liquid, Flammable is any liquid having a flashpoint below 100 0F (37.8 0C), except any Mixture having components with flashpoints of 100 0F (37.8 0C) or higher, the total of which make up 99 percent or more of the total volume of the Mixture.

4. Solid, Flammable is a solid, other than a blasting agent or Explosive as defined in 29 CFR 1910.109 (a), that is liable to cause fire through friction, absorption of moisture, spontaneous Chemical change, or retained heat from manufacturing or processing, or which can be ignited readily and when ignited burns so vigorously and persistently as to create a serious hazard. A Chemical shall be considered to be a Flammable Solid if, when tested by the method described in 16 CFR 1500.44, it ignites and burns with a self-sustained flame at a rate greater than one-tenth of an inch per second along its major axis.

J. Flashpoint is the minimum temperature at which a liquid gives off a vapor in sufficient concentration to ignite.

K. Foreseeable Emergency is defined as any potential occurrence such as, but not limited to, equipment failure, rupture of Containers, or failure of control equipment which could result in an uncontrolled release of a Hazardous Chemical into the Workplace.

L. Hazardous Chemical is any Chemical which is a Physical or a Health Hazard.

M. Hazard Warning is defined as any words, pictures, symbols, or combination thereof appearing on a Label or other appropriate form of warning which convey the specific Physical and Health Hazard(s), including target organ effects, of the Chemical(s) in the Container(s).

N. Health Hazard is a Chemical for which there is statistically significant evidence based on at least one study conducted in accordance with established scientific principles that acute or chronic health effects may occur in Exposed Employees. The term “Health Hazard” includes Chemicals which are carcinogens, toxic or highly toxic agents, reproductive toxins, irritants, corrosives, sensitizers, hepatotoxins, nephrotoxins, neurotoxins, agents that act on the hematopoietic system, and agents that damage the lungs, skin, eyes, or mucous membranes.

O. Label is any written, printed, or graphic material displayed on or affixed to Containers or Hazardous Chemicals.

P. Material Safety Data Sheets (MSDS) is a written or printed material concerning a Hazardous Chemical which is prepared in accordance with OSHA requirements.

Q. Mixture is defined as any combination of two or more Chemicals if the combination is not, in whole or in part, the result of a Chemical reaction.

R. Organic Peroxide is an organic compound that contains the bivalent -0-0- structure and which may be considered to be a structural derivative of hydrogen peroxide where one or both of the hydrogen atoms has been replaced by an organic radical.

S. Oxidizer is a Chemical other than a blasting agent or Explosive as defined in 29 CFR 1910.109(a), that initiates or promotes combustion in other materials, thereby causing fire either of itself or through the release of oxygen or other gases.

T. Physical Hazard is a Chemical for which there is scientifically valid evidence that it is a combustible liquid, a compressed gas, Explosive, Flammable, an Organic Peroxide, an Oxidizer, Pyrophoric, Unstable (Reactive) or Water-Reactive.  

U. Pyrophoric - is a Chemical that will ignite spontaneously in air at a temperature of 130 0F (54.4 0C) or below.  

V. Unstable (Reactive) is a Chemical which in the pure state, or as produced or transported, will vigorously polymerize, decompose, condense, or will become self-reactive under conditions of shocks, pressure or temperature.  

W. Water-Reactive is a Chemical that reacts with water to release a gas that is either Flammable or presents a Health Hazard.  

X. Work Area is a room or defined space in a Workplace where Hazardous Chemicals are produced or used, and where Employees are present.  

Y. Workplace is defined as an establishment, job site, or project, at a geographical location containing one or more Work Areas.

IV. PROCEDURE

A. Applicability 
This operating policy applies to Employees who may be Exposed to, under normal conditions of use or in a Foreseeable Emergency, a Hazardous Chemical which may be present in the Workplace. Employees who work in or visit Workplaces containing laboratories must also comply with the Chemical Hygiene Safety Program.  

B. Hazard Determination

1. A Hazardous Chemical is defined by OSHA as “any Chemical that is a Health Hazard or a Physical Hazard.” 1910.1200(c) “Definitions: Hazardous Chemical”

a. “Health Hazard is a Chemical for which there is statistically significant evidence based on at least one study conducted in accordance with established scientific principles that acute or chronic health effects may occur in Exposed Employees. The term "Health Hazard" includes Chemicals which are carcinogens, toxic or highly toxic agents, reproductive toxins, irritants, corrosives, sensitizers, hepatotoxins, nephrotoxins, and neurotoxins, agents which act on the hematopoietic system, and agents which damage the lungs, skin, eyes, or mucous membranes.” 1910.1200(c) Definitions

b. “Physical Hazard is a Chemical for which there is scientifically valid evidence that it is a Combustible Liquid, a Compressed Gas, Explosive, Flammable, an Organic Peroxide, an Oxidizer, Pyrophoric, Unstable (Reactive), or Water-Reactive.” 1910.1200(c) Definitions

c. Additional Hazardous Chemicals is a term OSHA uses to broadly define not only generic Chemicals but also paints, cleaning compounds, inks, dyes, and many other common substances. Chemical manufacturers and importers are required to determine if the Chemicals they produce or repackage meet the definition of a Hazardous Chemical. A Chemical Mixture may be considered as a whole or by its ingredients to determine its hazards. It may be considered as a whole if it has been tested as a whole and an MSDS has been issued accordingly. Otherwise the Mixture must be evaluated by its components. “If the Mixture contains 1.0 percent or more of a Hazardous Chemical or 0.1 percent of an ingredient listed as a carcinogen or suspected carcinogen, the whole Mixture is assumed to have the same Health and/or carcinogenic Hazards as its components.” 1910.1200(d)(5)(ii)

C. Chemical Inventory List 

1. Each Workplace supervisor will develop and maintain a Chemical Inventory List (CIL) alphabetically for every Hazardous Chemical known to be present in the Work Area(s). The identity of the Chemical appearing on the CIL must be the same name that appears on the manufacturer’s Label and the MSDS for that substance. The CIL will be updated by the Workplace supervisor when a new MSDS is received and before the introduction of a new Hazardous Chemical to accurately reflect all the Hazardous Chemicals present in each Workplace. The CIL will be electronically accessible by each Workplace using the ChemSW Chemical inventory system software. CIL is defined as “a list of the Hazardous Chemicals known to be present using an identity that is referenced on the appropriate Material Safety Data Sheet (the list may be compiled for the Workplace as a whole or for individual Work Areas).” 1910.1200(e)(1)(i)

2. Master Chemical Inventory List (MCIL) will be electronically accessible by the Office of Risk Management using the ChemSW Chemical Inventory system software. The Office of Risk Management will oversee a hard copy of the list and annual archiving of the MCIL. “An employer shall maintain a Workplace Chemical list for at least 30 years.” Texas Hazard Communication Act Sec. 502.005. 

D. Labeling Procedures

1. No Hazardous Chemical will be accepted for use at the Workplace, or shipped to any other Workplace or Work Area(s), unless Labeled with the following information:

a. Identity of the Hazardous Chemical(s).  

b. Appropriate Hazard Warnings.

c. Name and address of the Chemical manufacturer.

d. Importer or other responsible party.

2. No Hazardous Chemical may be used in the Work Area unless Labeled with at least the following information:

a. “Appropriate Hazard Warnings, or alternatively, words, pictures, symbols, or combination thereof, which provide at least general information regarding the hazards of the Chemicals, and which, in conjunction with the other information immediately available to Employees under the hazard communication program, will provide Employees with the specific information regarding the Physical and Health Hazards of the Hazardous Chemical.” 1910.1200(f)(5)(i)

b. “All Labels shall be legible, in English, and prominently displayed on the Container. The identity of the material that appears on the Label shall be the same as the Chemical name that appears on the manufacturer’s Material Safety Data Sheet (MSDS) and the Department’s CIL.” 1910.1200(f)(9)

c. “If the Hazardous Chemical is regulated by OSHA in a substance specific health standard, the Label used shall be in accordance with the requirements of that specific standard.” 1910.1200(f)(4)

d. “In certain situations involving individual stationary process Containers, the Label may be replaced by a sign, placard, process sheet, batch ticket, or other means to convey the identity of the Hazardous Chemical and the appropriate Hazard Warnings. If these other forms of warning are used, they must be readily accessible to Employees in their Workplace  or Work Area during each work shift.” 1910.1200(f)(6)

e. “Labels are not required on portable Containers into which Hazardous Chemicals are transferred from Labeled Containers, if and only if, the contents of the portable Container are intended for immediate use by the Employee who performed the transfer. Labeling of the portable Container will prevent any possible misuse of the material by others and is highly recommended. “Immediate use” means that the Hazardous Chemical will be under the control of and used only by the person who transfers it from a Labeled Container and only within the work shift in which it is transferred.”1910.1200(c)   

f. “Any portable Container of a Hazardous Chemical that is not intended for immediate use shall be properly Labeled by the Workplace. The “in-house” Label can be either hand-made or pre-printed and shall contain the information identified in Section 7.1. Employees with questions concerning the appropriate in-house label to use should refer to the manufacturer’s MSDS or ask their supervisor.” 1910.1200(f)(7)

g. “No Label on a Container is to be defaced or removed unless the Container is immediately marked with the required information. No Employee shall remove any Label unless specifically directed to do so by their supervisor. Any Container without a Label shall be immediately reported to the Work Area supervisor.” 1910.1200(f)(8)

E. Material Safety Data Sheets  

1. “Chemical manufacturers, suppliers, and importers of Hazardous Chemicals are required to develop and provide a Material Safety Data Sheet (MSDS) for their products.” 1910.1200(g)(1)

2. A MSDS provides detailed information concerning the Chemical’s composition, Health and Physical Hazards, proper disposal practices, and appropriate handling and control measures.

3. Each Workplace will maintain an electronically accessible file that contains copies of all manufacturers’ MSDS alphabetically for each Chemical listed on their CIL.

4. MSDS files will be electronically accessible by each Workplace using the ChemSW CIS chemical Inventory system software. This file will contain the most current version of the manufacturers’ MSDS. “The employer shall maintain in the Workplace copies of the required Material Safety Data Sheets for each Hazardous Chemical, and shall ensure that they are readily accessible during each work shift to Employees when they are in their Work Area(s). Electronic access, microfiche, and other alternatives to maintaining paper copies of the Material Safety Data Sheets are permitted as long as no barriers to immediate Employee access in each Workplace are created by such options.” 1910.1200(g)(8)

5. Each Workplace will maintain a hard copy of MSDS in a binder(s) Labeled MSDS to be located in a common Workplace area for emergency responders’ use or in the event of software or hardware malfunction or other unforeseeable emergency “to ensure that they are readily accessible with no barriers, with immediate employee access.” 1910.1200(g)(8)   

6. Each Workplace will maintain a hard-copy CIL to be used as an index for the MSDS hard copy. The index will be placed in the front of each Workplace MSDS binder with the following information:   

a. Hazardous Chemical common name, filed alphabetically.

b. Hazardous Chemical manufacturer’s name.

c. Hazardous Chemical MSDS location within the binder(s).

d. Hazardous Chemical location(s) within the Workplace.

e. Date of current MSDS.

f. Maximum quantity of Hazardous Chemical within the Workplace.

F. Employee Training

1. The supervisor will ensure each new Employee receives an introduction to the Hazard Communication Policy and completes the computer-based training during the Workplace new employee orientation.

2. Initial Training will be provided by the supervisor to each Employee on the Hazardous Chemical(s) in the Work Area(s) at the time of the initial assignment and will include the following as a minimum: 

a. Overview of the OSHA Hazard Communication Standard.  

b. How to recognize / detect the presence of Hazardous Chemicals in the Work Area.  

c. How to access and read an MSDS.

d. Labeling requirements and procedures.

e. Identification of Hazard Warning.  

f. Protective controls and measures.  

g. Workplace or Work Area specific procedures regarding Hazardous Chemicals.

3. Additional training will be provided by the supervisor to Employees upon the introduction of any new Physical or Health Hazard into their Work Area(s).   

4. Recommend supervisors document Hazard Communication training.  Documentation should be maintained in the Workplace.

5. Prior to performing any “non-routine” task that could involve Exposure to Hazardous Chemicals; the supervisor will review all the potential hazards of the task with the Employee(s). The supervisor will prescribe appropriate work practices and protective controls. The Office of Risk Management can provide consulting services to the Workplace on non-routine tasks.

G. Contractors

All contractors performing any work on University property must provide a list of all Hazardous Chemicals they will be using. The CIL will be provided to the contractor’s designated University liaison or project coordinator. The contractor will provide, upon request by the University, a copy of any and all MSDS for the Chemicals they are using. The University will provide, upon request, a copy of the University’s Hazard Communication Policy and inform the contractor, prior to the start of work, of the location of all known Hazardous Chemicals and potential
hazards that may be present in the Work Area.

H. Exemptions 

1. In accordance with the OSHA Hazard Communication Standard (29 CFR 1910.1200), the Hazard Communication Policy does not apply to:

a. Any hazardous waste subject to regulations issued under the Environmental Protection Agency’s (EPA) Solid Waste Disposal Act, Resource Conservation and Recovery Act (RCRA) of 1976.

b. Any hazardous substance which is the focus of remedial or removal action being conducted under the Comprehensive Environmental Response, Compensation and Liability Act (CERCLA).

c. Wood or wood products, including lumber which will not be processed, where the Chemical manufacturer or importer can establish that the only hazard they pose to Employees is the potential for Flammability or combustibility. Wood or wood products which have been treated with a Hazardous Chemical covered by the OSHA Hazard Communication Standard, and wood which may be subsequently sawed or cut, generating dust, are not exempt.

d. Articles defined as any manufactured item other than a fluid or particle which is formed to a specific shape or design during manufacture; has end use function(s) dependent in whole or part upon its shape or design during end use; under normal conditions of use does not release more than small (trace) quantities of a Hazardous Chemical; and does not pose a Physical Hazard or Health Hazard risk to Employees.

e. Foods which are sold, used, or prepared in a retail establishment and foods intended for personal consumption by Employees while in the Workplace.

f. Any drug, as defined in the Federal Food, Drug and Cosmetic Act, when it is in solid, final form for direct administration to the patient; any drugs which are packaged by the Chemical manufacturer for sale to consumers in a retail establishment; and any drugs intended for personal consumption by Employees while in the Workplace.

g. Cosmetics which are packaged for sale to consumers in retail establishments, and cosmetics intended for personal consumption by Employees while in the Workplace.

h. Any consumer product or hazardous substance as defined in the Consumer Product Safety Act or the Federal Hazardous Substance Act, where the employer can show that it is used in the Workplace for the purpose intended by the Chemical manufacturer or importer of the product; additionally, if the use of the product results in a duration and frequency of Exposure which is not greater than the range of Exposure that could reasonably be experienced by consumers when used for the intended purpose.

i. Nuisance particulates where the Chemical manufacturer or importer can establish that they do not pose any Physical or Health Hazard covered under the OSHA Hazard Communication Standard.

j. Ionizing and Non-ionizing Radiation.

k. Biological Hazards.

2. In accordance with the OSHA Hazard Communication Standard (29 CFR 1910.1200), the following items are exempt from labeling requirements:

a. Any pesticides that are subject to labeling requirements and regulations as defined in the Federal Insecticide, Fungicide, and Rodenticide Act, issued by the EPA.

b. Any Chemical substance or Mixture that is subject to labeling requirements and regulations as defined in the Toxic Substances Control Act (ToSCA), issued by the EPA.

c. Any food, food additive, color additive, drug, cosmetic, or medical or veterinary device or product, including materials intended for use as ingredients in such products, that is subject to labeling requirements and regulations as defined in the Federal Food, Drug, and Cosmetic Act or the Virus-Serum-Toxin Act of 1913, as issued by the Food and Drug Administration (FDA) or the Department of Agriculture, respectively.

d. Any consumer product or hazardous substance is subject to the labeling requirements and regulations as defined in the Consumer Product Safety Act and the Federal Hazardous Substances Act, respectively, as issued by the Consumer Product Safety Commission.

e. Agriculture or vegetable seed treated with pesticides as subject to labeling requirements and regulations as defined in the Federal Seed Act (7 U.S.C. 1551 et seq.) and the labeling regulations issued under that Act by the Department of Agriculture.

V. COMPLIANCE

1. The supervisor is responsible for implementing the program elements of this policy into their operations and ensuring compliance by their Employees.

2. All Employees are required to comply with the following guidance concerning OSHA inspections per Public Law 91-596 Occupational Safety and Health Act of 1970.  

SEC. 8. Inspections, Investigations, and Recordkeeping: Upon presenting appropriate credentials to the owner, operator, or agent in charge, representative is authorized to enter without delay and at reasonable times any factory, plant, establishment, construction site, or other area, Workplace or environment where work is performed by an Employee of an employer.

SEC. 9. Citations: Upon inspection or investigation, representative believes that an employer has violated a requirement of any regulations prescribed pursuant to this Act; he shall with reasonable promptness issue a citation to the employer.

SEC. 17. Penalties: Any employer who willfully or repeatedly violates the requirements of section may be assessed a civil penalty of not more than $70,000 for each violation, but not less than $5,000 for each willful violation.

3. Violations of this policy and/or procedures may result in disciplinary action or other action the University deems appropriate under the circumstances.

VI. MISCELLANEOUS

For the complete 29 CFR part 1910, subpart Z, Toxic and Hazardous Substances, Occupational Safety and Health Administration 
http://www.osha.gov/pls/oshaweb/owadisp.show_document?p_table=STANDARDS&p_id=9991

For the complete Public Law 91-596 84 STAT. 1590 91st Congress, S.2193 December 29, 1970, as amended through January 1, 2004. (1)
http://www.osha.gov/pls/oshaweb/owadisp.show_document?p_table=OSHACT&p_id=2743

For the complete State of Texas Health And Safety Code, Title 6. Food, Drugs, Alcohol, And Hazardous Substances, Subtitle D. Hazardous Substances, Chapter 502. Hazard Communication Act 
http://www.statutes.legis.state.tx.us/Docs/HS/htm/HS.502.htm

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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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Policy No. 740  

Revised: January 1, 2011   
Date of Scheduled Review: January 1, 2014 

University Driver Policy  
Responsible Department: Risk Management  
Responsible Administrator: Director of Risk Management
July 15, 2003   
 
PURPOSE  
To reduce liability claims, control insurance premium costs, and comply with our auto liability carrier’s stipulations by establishing a driving policy that outlines safety standards, driving terms and conditions, and additional requirements to help mitigate potential risks.

SCOPE  
This policy applies to all Employees authorized to operate University Vehicles or privately owned vehicles used in the course and scope of conducting University Business.  All vehicle operators are subject to this policy and must comply with the guidelines herein regardless of where the vehicle is being operated.  Portions of this policy may not be applicable to sworn ACUPD officers while operating police vehicles to conduct official duties.

DEFINITIONS  

  1. University Business is defined as any activity by an Employee that is determined to be within the scope of his or her assigned duties and includes University-sponsored or approved activities.
  2. Employee is defined as any individual currently classified as an employee by Human Resources and/or currently on the University payroll.
  3. Vehicle is defined as any motorized vehicle used to conduct business on behalf of the University, whether owned, leased, or rented by the University, by which persons or property can be transported.
  4. Routine Driver is defined as an Employee who is authorized to operate a Vehicle on a routine or regular basis (daily, weekly, or regularly scheduled) to conduct University Business.

PROCEDURE
A. Operating University Vehicles

In addition to establishing a driving policy, our auto liability carrier requires Abilene Christian University (ACU) to maintain a current listing of all Employees who are designated as Routine Drivers.  A Motor Vehicle Record (MVR) check will be conducted on all Routine drivers on an annual basis.  

Refer to Appendix A for details on MVR check procedures, insurance coverage, and driver training requirements.

1. Employees must meet the following terms and conditions prior to operating a Vehicle:

  • Use is for University Business;
  • Must be at least 18 years of age;
  • If under the age of 21, recommend supervisors only allow operation of a Vehicle within
  • 50 miles of the campus;  
  • Maintain a valid U.S. driver’s license; and
  • Complete applicable training.  

2. Refer to Appendix B for details on operating golf, utility cart-type, gator, or other off-road vehicles (ORVs).

3. Refer to Appendix C for detailed terms and conditions for operating passenger vans and buses.

4. The following safety standards must be complied with at all times while operating a Vehicle on University Business:

  • Comply with all traffic safety laws;
  • Enforce seatbelt requirements;
  • No driving while under the influence of drugs or alcohol;
  • No use of speed/radar detectors;
  • No speeding or reckless driving;
  • No use of headphones or ear buds while driving; 
  • No texting while driving; and
  • No use of cell phones while driving unless using a hands-free device.

5. The following uses are prohibited while operating Vehicles on University Business:

  • Transporting of passengers or material for compensation;  
  • Pushing another vehicle; 
  • Towing w/o prior permission from the Risk Management and Transportation offices; 
  • Transporting dangerous chemicals, flammable items, firearms, or other hazardous materials w/o prior approval of Risk Management; 
  • and Operating University-owned, leased, or rented vehicles outside the U.S. without prior approval of the Risk Management office.

B. Maintaining University Vehicles

1. The following are required to properly maintain Vehicles.

  • Vehicle inspection, registration, proof of insurance, and accident forms, must be current and maintained in each vehicle at all times.
  • Operators should report damage or other concerns to the Transportation Office.
  • Operators should monitor oil and other fluid levels and periodically check tire pressure and tread.

2. The following actions are recommended to secure Vehicles.

  • Take all reasonable precautions to prevent damage or theft of vehicles when parked or not in operation.
  • Roll up all windows and lock all doors.
  • Where possible, park in lighted and/or protected areas.

C. Operating Rental Vehicles

When unable to procure a vehicle through the Transportation office, renting a vehicle to conduct University Business is preferable to using a personal vehicle.  This helps control potential liability exposure to the University and/or the Employee.

  • Operators must meet the vehicle terms and conditions described in section A.1.
  • The vehicle must be rented for University Business.
  • Refer to Appendix D for details on obtaining and operating rental vehicles.

D. Operating Personal Vehicles

All Employees must meet the following terms and conditions to use their personal vehicle to conduct University Business:

  • Meet the vehicle operator terms and conditions described in section A.1;
  • Meet the insurance prerequisites in Appendix A, section C; and
  • The vehicle must be in good operating condition.

E. Vehicle Accident Procedures

1. All vehicle accidents must be reported to the Risk Management office as soon as possible but not to exceed 24 hours.

  • In the event of a serious injury or fatality, the vehicle operator will notify Risk Management at 325-674-2363 as soon as possible.
  • If the accident occurs outside normal business hours, the vehicle operator will notify ACU Police at 325-674-2911.

2. Refer to Appendix E for detailed information concerning vehicle accident and reporting procedures.

3. For any demand, claim, or summons served to an Employee involved in an accident asserting liability, contact the Risk Management office immediately.

COMPLIANCE  
Violations of these policies and/or procedures may result in disciplinary action or other action ACU deems appropriate under the circumstance. Furthermore, if an MVR check reveals that an Employee is uninsurable, the Employee’s driving privileges will be revoked.  The revocation period will be for three or five years, dependent upon the nature of the offense(s).  

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