HEAD START CHILD & FAMILY DEVELOPMENT CENTERS, INC.

BLOODBORNE PATHOGEN EXPOSURE CONTROL PLAN Revised by Health Services Advisory Committee April 2002 Reviewed and Approved by Policy Council September 12, 2002

HEAD START CHILD AND FAMILIY DEVELOPMENT CENTERS, INC. BLOOD BORNE PATHOGENS EXPOSURE CONTROL PLAN

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Blood borne pathogens are microorganisms found in human blood, which may cause disease to an individual exposed to them. The Blood borne Pathogens Standard (OSHA) was instituted to minimize the risk of individuals contracting diseases caused by exposure to blood borne pathogens, such as Hepatitis B or HIV. EXPOSURE DETERMINATION Employees exposed to blood or other body fluids containing blood in the course of their work who are covered with this standard are: 1) designated First Aid providers; and employees who might render First Aid only as a collateral duty; and classroom volunteers who render assistance in any situation involving the presence of blood or other potentially infectious materials. This exposure determination is made without regard to the use of personal protective equipment. A. Job classifications: Head Start has identified the following job classifications as those in which employees may be exposed to blood borne pathogens in the course of fulfilling their job requirements: Teacher Teacher Aide Special Needs Aide Interpreter/Aide Child and Family Services Manager Health Services Manager Classroom Volunteer B. Tasks and Procedures: Tasks/procedures which may put an employee at risk may include, but are not limited to the following: 1. Care of minor injuries that occur within a setting: bloody nose, abrasion, etc. 2. Initial care of injuries that require medical or dental assistance: damaged tooth, broken bone through skin, severe laceration, etc. 3. Care of children with medical needs: injections, blood glucose monitoring, etc. 4. Care of children who need assistance in daily living skills: toileting, dressing, feeding, tooth brushing, hand washing, etc. 5. Care of children who may exhibit behaviors that may injure themselves or others or produce blood, i.e., biting, hitting scratching, and spitting blood tinged saliva. 6. Cleaning tasks associated with body fluid spills. C. Exposure Incident: A specific eye, mouth, other mucous membrane, non-intact skin, or parenteral contact (needle sticks, human bites, cuts, or abrasions) with blood or other potentially infectious materials that results from the performance of an employee’s duties. D. Occupational Exposure: Reasonably anticipated skin, eye, mucous membrane, or parenteral contact (needle sticks, human bites, cuts, or abrasions) with blood or other potentially infectious materials that may result from the performance of an employee’s duties.

HEAD START CHILD AND FAMILIY DEVELOPMENT CENTERS, INC. BLOOD BORNE PATHOGENS EXPOSURE CONTROL PLAN METHODS OF COMPLIANCE

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The following methods of compliance are incorporated in the Head Start Blood borne Pathogens Exposure Control Plan: A. Universal Precautions: Requires the employee/volunteer to assume that all human blood and body fluids are infectious for HIV, Hepatitis B and other blood borne pathogens. Where differentiation of body fluids is difficult or impossible, all body fluids are to be considered potentially infectious. The term “body fluids” includes: blood, semen, drainage from wounds, cuts, and open lesions, feces, urine, vomitus, respiratory secretions (e.g., nasal drainage) and saliva. B. Work practice controls: Are designated to eliminate or minimize employee exposure. An exposure incident is defined as contact with blood or other potentially infectious materials on an employee’s mouth, eye, non-intact skin or mucous membrane or an exposure, which pierces the skin, or mucous membrane. An Exposure Incident Reporting/Evaluation Form will be completed by the exposed employee and submitted to the Health Services Manager immediately after an exposure incident occurs. 1. Hand Washing a. Hand washing facilities are readily accessible to employees in each Head Start Center with appropriate antiseptic cleansers. When hand-washing facilities are not readily accessible, a no-rinse hand wash solution is available for use. When using the no-rinse solution, hands will be washed with soap and running water as soon as available. b. Hand washing requires the use of soap and water and vigorous washing under a stream of running water for approximately 10 seconds. It is important to rinse under running water and use paper towels to thoroughly dry hands. c. Employees will wash hands and other affected areas with antiseptic cleanser as soon as possible after exposure. Employees will flush mucous membranes with water or eye wash solution, if needed. d. Employees shall wash their hands after removal of gloves or other personal protective equipment. Gloves are never to be reused. 2.

Personal Protective Equipment a. Forms of personal protective equipment to be utilized at Head Start include gloves, protective eye wear, disposable CPR masks, face shields/masks and gown. b. All classrooms will be equipped with gloves. Employees will be provided with latex or vinyl gloves that fit them properly. i. Gloves will be worn in anticipated contact with blood or other potential infectious material. ii. In the case of latex allergy, vinyl gloves will be worn. iii. Gloves will be discarded after one use. They will not be washed or decontaminated for re-use. iv. Replace gloves if torn, punctured, contaminated, or when their ability to function as a barrier has been compromised.

4 HEAD START CHILD AND FAMILIY DEVELOPMENT CENTERS, INC. BLOOD BORNE PATHOGENS EXPOSURE CONTROL PLAN 2. Personal Protective Equipment (cont) v. Contaminated disposable gloves are not considered to be regulated waste and does not need to be dispose of in red biohazard bags. vi. In the event an employee is allergic to latex or vinyl, hypoallergenic gloves will be made available. vii. A variety of glove sizes will be available to ensure proper fit. c. All Centers are equipped with an Eye Wash Station and employees will be made aware of the location and instructed on its use. d. Employees are provided with protective eyewear to utilize during tooth brushing. The protective eyewear is for employee individual use and will be cleaned by the employee who utilizes the eyewear. The eyewear will be replaced if broken or compromised for use. i. Face and eye protection will be worn whenever splashes, spray, spatter, or droplets of blood or other potentially infectious materials may generate eye, nose, or mouth contamination. e. All Centers are provided with a blood spill kit (gown, face shield, gloves, shoe covering) and a disposable CPR mask, which are stored in the classroom First Aid Kit. The First Aid kit is taken on the bus during any field trip. f. All classrooms are provided with a fanny pack containing band-aids, dressings, gloves, and no-rinse hand wash solution. A classroom employee will bring the fanny pack with for outside play, walks and field trips. g. Personal protective equipment will be readily accessible at each Center. Employees will be made aware of the location of this equipment at their work site and of the person in their Center responsible for insuring there are adequate supplies. h. Utility gloves are available and labeled for individual employee use while performing housekeeping duties. The utility gloves may be decontaminated for reuse if their integrity is not compromised. Discard utility gloves when they show signs of cracking, peeling, tearing, puncturing, or deteriorating. i. Employees shall notify the Health Services Manager of any personal protective equipment that needs to be repaired or replaced. Repair or replacement of personal protective equipment will be done at Head Start’s expense.

3.

Disinfectants a. An intermediate level disinfectant should be used to clean surfaces contaminated with body fluids. See the Daily Cleaning and Infection Control Manual for specific guidelines for cleaning hard surfaces and carpeting contaminated with body fluids. The disinfectant should be registered by the U.S. Environmental Protection Agency (EPA) for use as a disinfectant in medical facilities and hospitals. Various classes of disinfectant are listed below: i. Phenolic germicidal detergent in a 1% aqueous solution (e.g., Lysol) ii. Sodium Hypochloride with at least 100 parts per million available chloride (1/2 cup household bleach in one gallon water – freshly prepared daily) iii. Hydrogen peroxide iv. Quaternary ammonium germicidal in 2% aqueous solution (e.g., Tri-quat, Mytar or Sage)

5 HEAD START CHILD AND FAMILIY DEVELOPMENT CENTERS, INC. BLOOD BORNE PATHOGENS EXPOSURE CONTROL PLAN 4. Disinfection of hard surfaces and care of equipment a. See the Daily Cleaning and Infection Control Manual (Section 2, page 12) for specific guidelines for disinfection of hard surfaces and care of equipment. After soil is removed, a disinfectant should be applied. b. Mops should be soaked in the disinfectant after use and rinsed thoroughly or washed in a hot water cycle before rinse. c. Non-disposable cleaning equipment (dustpans, buckets) should be thoroughly rinsed in the disinfectant. d. Disposable cleaning equipment should be placed in the trash. e. The disinfectant solution should be promptly disposed down a drainpipe, such as a toilet or a utility sink.

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Disinfection of Rugs a. A sanitary absorbent agent should be applied, allowed to dry and then vacuumed. b. If necessary, mechanically remove with a dustpan and broom, and then apply Resolve Spot and Stain Carpet Cleaner. See the procedure outlined in the Daily Cleaning and Infection Control Manual (Section Two, page 17) for blood borne pathogen procedure for carpeting. c. The dustpan and broom should be rinsed and disinfected. The brush should be washed with soap and water and disinfected. d. Non-disposable cleaning equipment should be cleaned as noted in item 4.c.

6.

Waste Procedures a. Most waste can be disposed of in the regular waste system; regulated waste requires special handling. Regulated waste means liquid or semi-liquid blood or other potentially infectious materials; contaminated items that would release blood or other potentially infectious materials in a liquid or semi-liquid state if compressed; items that are caked with dried blood or other potentially infectious materials and are capable or releasing these materials during handling; contaminated sharps; and pathological and microbiological wastes containing blood or other potentially infectious materials. i. Materials that are considered regulated waste must be put in a red biohazard bag or sharps container. Biohazard bags are found in the First Aid kits in each classroom. ii. Delivery and verification of regulated waste by the contracted disposal provider will be done in accordance to DNR regulations. (Federal/State/Local Waste Regulations) b. All procedures involving blood or other potentially infectious materials will be performed with minimal splashing, spraying, splattering, and generation of droplets. Clean and decontaminate all equipment and environmental and work surfaces immediately that has been contaminated with blood and other potentially infectious materials. (See Daily Cleaning and Infection Control Manual) c. Decontaminate work surfaces with appropriate disinfectant, immediately when overtly contaminated, after any spill of blood or other potentially infectious materials, and at the end of the workday when surfaces have become contaminated since the last cleaning.

6 HEAD START CHILD AND FAMILIY DEVELOPMENT CENTERS, INC. BLOOD BORNE PATHOGENS EXPOSURE CONTROL PLAN 6. Waste Procedures (cont) d. Inspect and decontaminate, on a regular basis, reusable receptacles such as bins, pails, and cans that have likelihood for becoming contaminated. When contamination is visible, clean and decontaminate receptacles immediately. e. Contaminated sharps, broken glass, plastic, or other sharp objects shall be placed into appropriate biohazard sharps containers. These containers shall be closable, puncture resistant, leak proof, and labeled with the biohazard label. Containers shall be maintained in the upright position. Containers shall be located in areas where sharps are used or can be reasonably anticipated to be found and are easily accessible to staff. i. Always use mechanical means such as a brush, broom and a dustpan to pick up contaminated broken glass; never pick up with hands even if gloves are worn. This glass shall be discarded into a biohazard sharps container for disposal. ii. Employees shall not reach into these containers to pick items out. Needles/lancets may not be recapped, removed, sheared, or purposely broken before disposal. iii. When a biohazard container becomes ¾ full, the Health Services Manager will be notified to have this container removed and a replacement made available. f. A licensed waste hauler will haul all containers and bags with non-reusable contaminated materials for proper disposal in accordance with applicable regulations of Wisconsin and the United States. The disposal of these containers and bags will be the responsibility of the Health Services Manager. i. Health Services Manager will contact the infectious waste controller (Franciscan Skemp Healthcare, La Crosse) to dispose of all containers and bags with non-reusable contaminated materials, such as sharps containers. g. If clothing and/or other washable materials are contaminated with blood or other potentially infectious materials, the following procedures are applicable; i. If blood or other potentially infectious materials contaminate clothing, the clothing will be disinfected or removed immediately. ii. Employees shall keep a change of clothing available at their work site in case of clothing contamination of blood or body fluids. iii. Gloves shall be used when handling contaminated laundry. Place wet contaminated laundry in leak-proof, labeled or color-coded containers before transporting. Do not sort or rinse prior to bagging. iv. Head Start is responsible for laundering contaminated laundry. Head Start employees responsible for laundry will contact the Health Services Manager of contaminated laundry needing special treatment. v. Clothing soaked with body fluids will be washed separately from other items. vi. Contaminated laundry should be stored in a safe area, separate from other laundry. h. Sanitary absorbent agents specifically intended for cleaning body fluid spills will be available to be used in each Center. Gloves should be worn when using these agents.

7 HEAD START CHILD AND FAMILIY DEVELOPMENT CENTERS, INC. BLOOD BORNE PATHOGENS EXPOSURE CONTROL PLAN 6. Waste Procedures (cont) i. The dry material should be applied to the area as directed, left on the area for the recommended time and then swept up. The contaminated material should be disposed of in a labeled container. The broom and dustpan should be rinsed in a disinfectant. i. Materials such as paper towels, gauze, towels, or clothing that are soaked or caked with blood or other potentially infectious materials shall be bagged and tied into an impervious designated red biohazard bag. Items going in these red bags should be sorted according to disposable items, towels, and personal clothing.

HEPATITIS B VACCINATION A. The Hepatitis B vaccination series (HBV) is available for employees who render First Aid only as a collateral duty responding solely to injuries resulting from workplace incidents. 1. Hepatitis B vaccine will be made available to unvaccinated employees who may be “reasonably anticipated” to come into contact with human blood and other potentially infectious materials, which include any body fluid that is visibly contaminated with blood. Those employees eligible for the vaccination series are listed under “Job Classifications”. (Exposure Determination, Section A.) The vaccine will be made available after pre-service training and within 10 working days of the employee’s initial assignment. 2. Employees will complete Hepatitis B Vaccination Series Consent/ Declination after staff orientation is completed. All records received regarding the Hepatitis B vaccination series will be maintained in the employee’s personnel files. 3. The Hepatitis B vaccine may be obtained at no cost to employee requesting the vaccination. Employees will be responsible to complete the vaccination series on their own time. Employees requesting the vaccine will obtain it at the County Health Department in their community, identifying themselves as a Head Start employee. Billing will be forwarded to Head Start Central Office. 4. If a Head Start employee initially declines the Hepatitis B vaccine, but decides to accept the vaccine at a later date while still covered under the standard, Head Start shall make available the Hepatitis B vaccine at such time. 5. Two months after an employee completes the Hepatitis B vaccination series, they will be requested to obtain a post-vaccine serum antibody test at no cost to the employee. The Health Services Manager will notify Franciscan Skemp Occupational Health Department of eligible employees. Individual employees will schedule an appointment through the clinic in their county for the serum antibody test, identifying themselves as a Head Start employee. Employees who decline the post vaccine antibody test must sign a declination statement. Employees showing immunity require no additional vaccinations. Employees who have a negative antibody test will need a second series of Hepatitis B vaccinations followed by another antibody test two months after the last injection in the second series. This will be offered at no expense to the employee.

HEAD START CHILD AND FAMILIY DEVELOPMENT CENTERS, INC. BLOOD BORNE PATHOGENS EXPOSURE CONTROL PLAN

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B. Post-Exposure Evaluation and Follow-Up 1. All First Aid incidents involving exposure to blood shall be reported to the Health Services Manager and to the employee’s supervisor by the end of the workday on which the incident occurred. 2. Employees must complete the Exposure Incident Reporting/Evaluation form and send to the Central Office. Each Center has a supply of these forms for employee use. The completed form will be maintained in the employee’s personnel file. 3. At no cost, Head Start will make available to the exposed employee a confidential medical exam (see Post Exposure Protocol) and follow up including the following elements: a. Documentation of the route(s) of exposure and the circumstances under which the exposure incident occurred. b. Identification and documentation of the source individual unless it can be established that identification is not feasible or prohibited by State or local law. c. After the consent is obtained, the source individual’s blood shall be tested as soon as feasible, in order to determine HBV and HIV infectivity. The Health Services Manager shall contact the source person or his/her parent or guardian for consent to have the source person’s blood tested for HBV and HIV. If consent is not obtained, the Head Start Executive Director shall establish that legally required consent cannot be obtained. d. The results of the source individual’s testing shall be made available to the exposed employee and the employee shall be informed of applicable laws and regulations concerning disclosure of the identity and infectious status of the source individual. e. The exposed employee’s blood shall be collected as soon as feasible and tested after consent is obtained. If the employee consents to baseline blood collection, but does not give consent at that time for HIV serologic testing, the sample shall be preserved for at least 90 days. If, within 90 days of the exposure incident, the employee elects to have the baseline sample tested, such testing shall be done as soon as feasible. f. The Occupational Health Department and/or Public Health Department will provide counseling relating to the implications of testing and post-exposure prophylaxis. g. The Hepatitis B vaccination series will be made available as soon as possible but in no event later than 24 hours, to all unvaccinated first aid providers involved in an exposure incident.

HEAD START CHILD AND FAMILIY DEVELOPMENT CENTERS, INC. BLOOD BORNE PATHOGENS EXPOSURE CONTROL PLAN C.

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Healthcare Professional’s Written Opinion 1. Head Start shall obtain and provide the employee with a copy of the evaluating healthcare professional’s written opinion within 15 days of the completion of the evaluation. The healthcare professional’s written opinion for Hepatitis B vaccination shall be limited to whether Hepatitis B vaccination is indicated for an employee, and if the employee has received such vaccination. The written opinion shall also include: a. Documentation ensuring that the employee has been informed of the results of the evaluation. b. Documentation ensuring that the employee has been told about any medical conditions resulting from exposure to blood or other potentially infectious materials, which require further evaluation or treatment.

D.

Information and Training 1. Head Start will ensure that all employees with potential for exposure to blood borne pathogens participate in a training program during work time at no cost to the employee. a. Training will be provided at the time of initial assignment to tasks, which may involve occupational exposure. b. Annual update and training will be provided to all employees with potential for exposure to blood borne pathogens. 2. The training will include (but not limited to) the following elements: a. Information on the epidemiology and symptoms of blood borne diseases; b. Ways in which blood borne pathogens are transmitted; c. Explanation of the Communicable Disease Policy and how to obtain a copy; d. Information on how to recognize tasks that might result in occupational exposure; e. Explanation of the use and limitations of work practice controls and personal protective equipment; f. Information on the types, selection, proper use, location, removal, handling, decontamination, and disposal of personal protective equipment; g. Information on Hepatitis B vaccination such as safety, benefits, efficacy, methods of administration, and availability; h. Information on who to contact and what to do in an emergency; i. Information on how to report an exposure incident and the elements of postexposure evaluation and follow-up; j. Question and answer session on any session of the training.

HEAD START CHILD AND FAMILIY DEVELOPMENT CENTERS, INC. BLOOD BORNE PATHOGENS EXPOSURE CONTROL PLAN E.

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Record keeping 1. Medical Records a. Head Start shall establish and maintain an accurate record for each employee with occupational exposure, in accordance with 29 CFR 1910.20. These records will be maintained by the Health Services Coordinator and kept with the employee’s personnel records in a separate confidential file. These records shall include: ii. The name and social security number of the employee; iii. A copy of the employee’s Hepatitis B vaccination status including the dates of all the Hepatitis B vaccinations and any medical records relative to the employee’s ability to receive vaccination as required or declination form; iv. If exposure incident(s) have occurred, a copy of all results of examinations, medical testing, post-exposure evaluation, and follow-up procedures; v. If exposure incident(s) have occurred, a copy of the healthcare professional’s written opinion; vi. If exposure incident(s) have occurred, a copy of the information provided to the healthcare professional; i.e., exposure incident reporting/evaluation form, Head Start Employee HBV Vaccination Record, etc.

F.

Confidentiality 1. Head Start shall ensure that employee medical records required by this policy are kept confidential and are not disclosed or reported without the employee’s expressed written consent to any person within or outside of Head Start, except as required by law. These medical records shall be kept separate from other personnel records. 2. These medical records shall be maintained for the duration of employment plus 30 years.

G.

Training Records 1. Training records shall be maintained for three years from the date on which the training occurred. Training records shall include the following: a. The dates of the training sessions; b. The contents or summary of the training sessions; c. The names and qualifications of person(s) conducting the training; d. The names and job descriptions of all persons attending the training sessions.

HEAD START CHILD AND FAMILIY DEVELOPMENT CENTERS, INC. BLOOD BORNE PATHOGENS EXPOSURE CONTROL PLAN H.

Availability of records 1. Head Start shall ensure that: a. All required maintained records would be made available upon request to the Director of the National Institute of Occupational Safety and Health (NOSH) and to the Assistant Secretary of Labor For Occupational Safety and Health for examination. b. All required employee-training records would be provided upon request for examination to employees. Employee’s medical records will be available to the individual employee or anyone having that employee’s written consent. c. Head Start will comply with the requirements involving the transfer of records set forth in this standard.

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HEAD START CHILD AND FAMILIY DEVELOPMENT CENTERS, INC. BLOOD BORNE PATHOGENS EXPOSURE CONTROL PLAN

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HEPATITIS B VACCINATION SERIES CONSENT/DECLINATION Employee Name (Print):______________________________________Social Security No.__________________ Last

First

MI

Work Location:______________________________________________Position:_____________________________ I have been informed of the symptoms and modes of transmission of blood borne pathogens including Hepatitis B virus (HBV). I know about Head Start’s Blood borne Pathogen Exposure Control Plan and understand the procedure to follow if an exposure incident occurs. I understand that the Hepatitis B vaccination is available, at no cost, to employees whose jobs involve the risk of directly contacting blood or other potentially infectious material. I understand that vaccinations shall be given according to recommendations for standard medical practice in the community.

SIGN A OR B BELOW (ONE ONLY). A.

HEPATITIS B VACCINE CONSENT I consent to administration of the Hepatitis B vaccine. I have been informed of the method of administration, the risks, and benefits of the vaccine. I understand that Head Start is not responsible for any reactions caused by this vaccine. X_________________________________________________ Employee’s Signature

B.

____________/__________/___________ Date

HEPATITIS B VACCINE DECLINATION 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 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. X__________________________________________________ Employee’s Signature

____________/__________/___________ Date

Optional Information: Reason for Declination:

Already vaccinated Allergic to yeast Prefer to consult my doctor before accepting vaccine Other

Consents: Call County Health Department for vaccination appointment. Bring vaccination record to scheduled appointment.

HEAD START CHILD AND FAMILIY DEVELOPMENT CENTERS, INC. BLOOD BORNE PATHOGENS EXPOSURE CONTROL PLAN

EMPLOYEE HBV VACCINATION RECORD Employee:___________________________________________

Social Security #:______________________

Address:_____________________________________________

Phone # (Work):_______________________

_____________________________________________

(Home):_______________________

Position:_____________________________________

Work Location:________________________

Print Name

Street

Apt. #

City

State

HBV Vaccination #1 Date:_________________ Injection Site:_________________________

Dose:____________________

Manufacturer:_______________________________________ Lot No :_____________________________ Administered by:___________________________________________________________________________ Signature and Title

Next Dose Due:________________________________ Enter Date

HBV Vaccination #2 Date:_________________ Injection Site:_________________________

Dose:____________________

Manufacturer:_______________________________________ Lot No :_____________________________ Administered by:___________________________________________________________________________ Signature and Title

Next Dose Due:________________________________ Enter Date

HBV Vaccination #3 Date:_________________ Injection Site:_________________________

Dose:____________________

Manufacturer:_______________________________________ Lot No :_____________________________ Administered by:___________________________________________________________________________ Signature and Title

Post Vaccine Antibody Test:

Date:_____________________

Results:________________________________________________

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HEAD START CHILD AND FAMILIY DEVELOPMENT CENTERS, INC. BLOOD BORNE PATHOGENS EXPOSURE CONTROL PLAN

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HEPATITIS B POST-VACCINE ANTIBODY TEST DECLINATION

Employee Name (Print):______________________________________Social Security No.__________________ Last

First

MI

Work Location:______________________________________________Position:_____________________________

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 completed the Hepatitis B vaccination series. I have been given the opportunity to be tested for the Hepatitis B vaccine surface antigen, at no charge to myself. However, I decline Hepatitis B vaccination serum antibody test. X__________________________________________________ Employee’s Signature

____________/__________/___________ Date

HEAD START CHILD AND FAMILIY DEVELOPMENT CENTERS, INC. BLOOD BORNE PATHOGENS EXPOSURE CONTROL PLAN

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EXPOSURE INCIDENT REPORTING/EVALUATION FORM Instructions: Complete this form to document the routes of exposure and how the exposure incident has occurred. This form will be maintained in the employee’s confidential medical file with all results of examinations, medical testing and follow-up procedures. 1.

Employee Name:___________________________________________________________________

2.

Date of Incident:____________________ Location of Incident:_________________________

3.

Description of employee’s duties during the exposure incident:_______________________ ____________________________________________________________________________________ ____________________________________________________________________________________

4.

The route of exposure was: a. Needle stick with contaminated needle to_____________________________________ b. Piercing of skin with contaminated sharp to___________________________________ c. Splashing/spraying of blood or other potentially infectious material to___________ _____________________________________________________________________________ d. Other________________________________________________________________________

5.

Describe the circumstances under which the exposure incident occurred: ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ ____________________________________________________________________

6.

How was the incident caused: (accident, equipment malfunction, etc. List any tool, machine, or equipment involved):__________________________________________________ ___________________________________________________________________________________

7.

Personal protective equipment used at the time of the incident:______________________ ____________________________________________________________________________________

8.

Actions taken (decontamination, clean-up, reporting, etc.):__________________________ ________________________________________________________________________________________ ________________________________________________________________________________

9.

Recommendations for avoiding repetition of incident:________________________________ ________________________________________________________________________________________ ________________________________________________________________________________

Employee Signature:_____________________________________ Date:__________________________

HEAD START CHILD AND FAMILIY DEVELOPMENT CENTERS, INC. BLOOD BORNE PATHOGENS EXPOSURE CONTROL PLAN

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TRAINING OF EMPLOYEES WITH POTENTIAL EXPOSURE OF BLOOD BORNE PATHOGENS Date of Training:

________________________________________________________________________

Trainer Name and Qualifications:

______________________________________________________

Names and job titles of employees attending:

(Attached)

Agenda and/or materials presented to participants include: _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____

A general explanation of the epidemiology and symptoms of blood borne pathogens. Explanation of the modes of transmission of blood borne pathogens. Explanation of the Blood borne Exposure Control Plan. Explanation of the tasks/activities that may involve exposure to blood or other potentially infectious materials. Explanation of the use and limitations of methods that will prevent or reduce exposure. Information on the types, proper use and disposal of personal protective equipment. Information on the HBV vaccine, safety, method of administration, benefits of vaccination and the availability at no cost to the employee. Information on the appropriate actions to take and persons to contact in an emergency exposure situation. Explanation of the procedure to follow if an exposure occurs, the method of reporting and the medical follow-up needed. Question and Answer session provided by the trainer with the employees. Possible contacts within the health community who may be resources to the employees if they have further questions. Review of correct hand washing techniques.

Signature of Trainer:________________________________________Date:_________________________

HEAD START CHILD AND FAMILIY DEVELOPMENT CENTERS, INC. BLOOD BORNE PATHOGENS EXPOSURE CONTROL PLAN

BLOOD BORNE PATHOGEN – POST EXPOSURE PROTOCOL

BLOOD BORNE PATHOGEN POST EXPOSURE TREATMENT FACILITIES FOR HEAD START EMPLOYEES AND AUTHORIZED VOLUNTEERS The Clinics listed below are designated to provide post exposure evaluation and treatment to Head Start employees and authorized volunteers. The Clinics will ensure the necessary documentation is completed and forwarded to the Head Start Central Office. All costs incurred with clinic visit will be covered by Head Start’s workman’s compensation insurance at no cost to the Head Start employee or volunteer. •

La Crosse County:

•

Monroe County:

Franciscan Skemp Occupational Health 630 South 10th Street La Crosse, WI 54601 (608) 791-9769 Hours: 7:00 am – 4:30 pm* Monday – Friday No appointments necessary *After hours, utilize the Walk – In Clinic or the Emergency Room Franciscan Skemp – Occupational Health/Hospital 310 West Main Street Sparta, WI 54656 (608) 269-2132 Hours: 8 am – 5 pm Monday – Friday

Franciscan Skemp – Lake Tomah Clinic 325 Butts Avenue Tomah, WI 54660 (608) 372-5951 Hours: 8 am – 8 pm, Monday – Thursday 8 am – 5 pm, Friday Call to set up appointment with on-call physician the day of exposure. Identify reason needing medical care. Crawford County:

Franciscan Skemp – Prairie du Chien Clinic 800 East Blackhawk Avenue Prairie du Chien, WI 53821 (608) 326-0808 Hours: 8 am – 8 pm, Monday & Wednesday 8 am – 5 pm, Tuesday, Thursday, Friday • Vernon County: Vernon Memorial Hospital 507 South Main Street Viroqua, WI 54665 (608) 637-2101 Report to the Emergency Room the day of exposure. Identify self as Head Start employee. •

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