Policies and procedures
The University of Wisconsin - La Crosse has developed written policies, programs, procedures and other similar documents to enhance our commitment to environmental health and safety issues. Our goal in communicating this information is to empower our faculty, staff, students and other members of our campus community to participate in the continuing effort to improve our working, learning and physical environments. An interested and active commitment by ALL campus community members is the key to improving the safety and healthfulness of our working and learning environments.
This Bloodborne Pathogens Exposure Control Standard applies to all University of Wisconsin - La Crosse employees whose position duties may reasonably be anticipated to result in occupational exposure to blood or other potentially infectious materials. (Other potentially infectious materials and other phrases and words are defined on page 2, under Key Definitions.) The personnel affected by the Standard are identified in Section I on Exposure Determination. The purpose of the UW-L plan is to provide information which will assist personnel in minimizing or eliminating their potential exposure to human immunodeficiency virus (HIV), hepatitis B (HBV), and other bloodborne pathogens. The secondary purpose is to comply with Occupational Safety and Health Administration (OSHA) regulations as enforced by the Wisconsin Department of Industry, Labor and Human Relations (DILHR).
Employees in certain occupations face an increased health risk as a result of potential exposure to blood and other infectious materials which may contain bloodborne pathogens. Such pathogens include hepatitis B virus (HBV), which may cause a serious liver disease, and human immunodeficiency virus (HIV), which causes Acquired Immunodeficiency Syndrome (AIDS). These health risks can be minimized by using a combination of universal precautions, engineering and work practice controls, personal protective equipment, scrupulous housekeeping, training, appropriate vaccination, and medical evaluation and treatment following any actual exposure incidents.
All costs associated with program implementation will be funded by the University of Wisconsin. As follows, expenses or charges at the University of Wisconsin - La Crosse will be funded through centralized university funds or decentralized department funds.
- Post-exposure and follow-up evaluations conducted by private or contract healthcare professional.
- Regulated waste disposal.
- Personal protective equipment (PPE) and spill response kits.
- Appropriately color-coded or labeled waste receptacles.
- Any engineering controls necessary to implement the program.
- Biohazard warning labels and signs.
- Hepatitis B vaccination series and future booster vaccinations provided by the Health Center.
Every University of Wisconsin - La Crosse employee has personal responsibility for compliance and implementation of this written Bloodborne Pathogens Program. Generic responsibilities of identified organizations or personnel are as described below; refer to the written Program for a detailed description of responsibilities.
Appendix A contains a schedule for specific organization and individual implementation and compliance assignments.
Ultimately responsible for the UW-L compliance and implementation of the Bloodborne Pathogen Exposure Control Standard.
Environmental Health and Safety shall:
- Administrate implementation of the Bloodborne Pathogens Program.
- Conduct or arrange for training of personnel with occupational exposure.
- Conduct unannounced periodic inspections to evaluate program compliance.
- Coordinate biohazard waste disposal.
- Assist supervisors and others with determining the correct type of PPE.
- Annually review the written program and update as needed.
- Investigate and recommend methods to correct events where PPE is not used because it would have prevented the delivery of health care or would have posed an increased risk to any individual.
Health Center shall:
- Provide consultative medical services related to implementation of the Bloodborne Pathogens Program.
- Provide hepatitis B vaccinations, as requested.
- Coordinate vaccination recordkeeping and scheduling requirements with Human Resources, supervisor and employee.
Human Resources shall:
- Complete OSHA recordkeeping requirements and maintain employee medical records related to the
- Maintain training and exposure determination records.
- Work with employee to coordinate scheduling of post-exposure evaluations and follow-ups with private or contract healthcare professionals.
Supervisors and Directors shall:
- Ensure that safe work practices, controls and PPE are being correctly utilized.
- Ensure availability of adequate PPE supplies.
- Develop specific written guidelines, if not already provided in Section III (Engineering and Work Practice Controls), to address unique hazards associated with their laboratory procedures or equipment.
- Familiarize their employees with the contents of Appendix C or C2.
- Arrange to conduct an exposure incident investigation, with the Environmental Health and Safety Office, to develop and recommend methods to prevent recurrence of similar incidents.
- Document annually consideration and implementation of appropriate commercially available and effective medical devices designed to eliminate or minimize occupational exposure.
All Employees shall:
- Familiarize themselves with the contents of Appendix C or C2 and their responsibilities listed therein.
- Immediately report an exposure incident to their Supervisor and Human Resources. If the Human Resources is not available, contact Protective Services.
Employees with occupational exposure shall:
- Question their immediate supervisor regarding any point of the program they do not understand.
- Use PPE as directed in training, written area procedures and by their supervisor.
- Use engineering and administrative controls to minimize or eliminate exposure.
- Maintain facilities which use blood or other potentially infectious materials in a clean and sanitary condition.
- Coordinate with supervisor and Health center the scheduling of Hepatitis B vaccinations.
Custodial Staff shall:
- Perform housekeeping responsibilities in common area's and support cleaning activities in other area's.
Course Instructors, Coaches, etc. shall:
- Minimize or eliminate the use of human blood and other potentially infectious materials in all curricula.
- Observe and familiarize their students, team members and similar individuals with requirements specified in the policy on students in Section XV.
Ensure that compliance with the OSHA Standards is included as a contract requirement whenever contract service or contract labor is procured.
University Police shall:
- Coordinate emergency response activities.
Appropriately labeled or Color-coded means the following: "Label" refers to the universal biohazard symbol, printed in fluorescent orange or orange-red color, with the word "Biohazard" printed in contrasting color. "Color-coded" refers to bags or containers that are red.
Bloodborne pathogens means pathogenic microorganisms that are present in human blood and can cause disease in humans. These pathogens include, but are not limited to, hepatitis B virus (HBV) and human immunodeficiency virus (HIV).
Contaminated means the presence or the reasonably anticipated presence of human blood or other potentially infectious materials on an item or surface.
Contaminated laundry means laundry which has been soiled with blood or other potentially infectious materials.
Contaminated sharps means any contaminated object that can penetrate the skin including, but not limited to needles, scalpels, broken glass, broken capillary tubes, and exposed ends of deutal wires.
Decontamination means the use of physical or chemical means to remove, inactivate, or destroy bloodborne pathogens on a surface or item to the point where they are no longer capable of transmitting infectious particles and the surface or item is rendered safe for handling, use, or disposal.
Engineering controls means controls (e.g., sharps disposal containers, self-sheathing needles, safer medical devices, such as sharps with engineered sharps, injury protections and needleless systems) that isolate or remove the bloodborne pathogens hazard from the work-place.
Exposure incident means a specific eye, mouth, other mucous membrane, non-intact skin, or parenteral contact with blood or other potentially infectious materials that results from the performance of an employee's duties.
Hand washing facilities means a facility providing an adequate supply of running potable water, soap and single use towel or hot air drying machines.
HBV means hepatitis B virus.
HIV means human immunodeficiency virus.
Needleless Systems means a device that does not use needles for: (1) The collection of bodily fluids or withdrawal of body after initial venous or arterial access is established; (2) The administration of medication or fluids; or (3) And other procedure involving the potential for occupational expose to bloodborne pathogens due to percutaneous injuries from contaminated sharps.
Occupational exposure means reasonably anticipated skin, eye, mucous membrane, or parenteral contact with blood or other potentially infectious materials that may result from the performance of an employee's duties.
Other potentially infectious materials means (1) The following human body fluids: semen, vaginal secretions, cerebrospinal fluid, synovial fluid, pleural fluid, pericardial fluid, peritoneal fluid, amniotic fluid, saliva in dental procedures, any body fluid that is visibly contaminated with blood, and all body fluids in situations where it is difficult or impossible to differentiate between body fluids; and (2) any unfixed tissue or organ (other than intact skin) from a human (living or dead); and (3) HIV-containing cell or tissue cultures, organ cultures, and HIV- or HBV-containing culture medium or other solution; and blood, organs, or other tissue from experimental animals infected with HIV or HBV.
Parenteral means piercing mucous membranes or the skin barrier through such events as needle-sticks, human bites, cuts and abrasions.
Personal protective equipment (PPE) is specialized clothing or equipment worn by an employee for protection against a hazard. General work clothes (e.g., uniforms, pants, shirts or blouses) not intended to function as protection against a hazard are not considered personal protective equipment.
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 are capable of releasing these materials during handling; contaminated sharps, pathological and microbiological wastes containing blood or other potentially infectious materials.
Sharps with engineered sharps injury protections means a non-needle sharp or a needle device used for withdrawing body fluids, accessing a vein or artery, or administering medications or other fluids, with a built-in safety feature or mechanism that effectively reduces the risk of an exposure incident.
Source individual means any individual, living or dead, whose blood or other potentially infectious materials may be a source of occupational exposure to the employee. Examples include, but are not limited to, hospital and clinic patients; clients in institutions for the developmentally disabled; trauma victims; clients of drug and alcohol treatment facilities; residents of hospices and nursing homes; human remains; and individuals who donate or sell blood or blood components.
Universal precautions is an approach to infection control. The approach treats all human blood and certain human body fluids as if known to be infectious for HIV, HBV, and other bloodborne pathogens.
Work practice controls means controls that reduce the likelihood of exposure by altering the manner in which a task is performed. (e.g. prohibiting recapping of needles by a two-handed technique.)
I. EXPOSURE DETERMINATION
All University of Wisconsin - La Crosse employees in the following job classifications have occupational exposure.
- Health Center Nurses
- Laboratory Technicians in Health Center
- Medical Technology staff
- Campus Police and Security Officers
- Sports Medicine Specialists
- Athletic Department first aid providers and lifeguards
- Environmental Health and Safety staff
- Electricians and personnel that are safety back-ups for personnel that work on energized electrical systems.
- Custodial Staff in campus buildings.
Some University of Wisconsin - La Crosse employees in the following job classifications have occupational exposure. Specific exposure tasks are identified after the job classifications.
- Coaches and Trainers from the Athletic Department who are involved with providing first aid treatment and/or handling contaminated laundry.
- Researchers, Instructors, student employees or other personnel from any laboratory where human blood or other infectious materials are used or studied.
- Persons in any job title who are engaged in drawing human blood or obtaining samples of other potentially infectious materials.
- Any first-aid or cardio-pulmonary resuscitation (CPR) trained personnel who have been specifically authorized through a written job description to respond to emergencies that may involve blood or other potentially infectious materials.
- All personnel involved in handling or transporting regulated infectious waste.
- Laundry workers who handle contaminated laundry and any employee's who handle contaminated laundry.
- Personnel who work on effluent plumbing systems or other equipment which may be contaminated with blood or other potentially infectious materials.
- Child Care Center employees who are required by Wisconsin statute to provide first-aid services.
Personnel required to perform these activities as part of their assigned job duties have occupational exposure and are affected by the Standard.
Personnel that are included in this list are required to comply with all requirements of the Bloodborne Pathogen Exposure Control Standard.
Students are not affected by this Standard unless they are employed, and receive monetary payment, from the University of Wisconsin in one of the above listed job classifications or job class specific tasks. However, the University of Wisconsin - La Crosse will take action to minimize or eliminate students exposure to blood and other potentially infectious materials in courses and other campus sponsored activities.
II. UNIVERSAL PRECAUTIONS
All University of Wisconsin personnel with occupational exposure are to observe universal precautions.
Universal precautions apply to blood and other potentially infectious materials. Universal precautions do not apply to feces, nasal secretions, sputum, saliva, sweat, tears, urine, and vomitus, unless they contain visible blood. Under circumstances in which differentiation between body fluid types is difficult or impossible (such as certain emergency response situations), all body fluids should be considered potentially infectious.
III. ENGINEERING AND WORK PRACTICE CONTROLS
The following engineering and work practice controls shall be observed and implemented by all UW - La Crosse employees who have occupational exposure:
- Hand washing facilities shall be readily accessible. Where provision of such facilities is not feasible, antiseptic cleansers or towelettes shall be used, followed as soon as possible by hand washing.
- All employees shall wash their hands immediately or as soon as feasible after removal of gloves or other PPE.
- All employees are to wash their hands and any other skin with soap and water or to flush mucous membranes with water immediately or as soon as feasible following contact of such body areas with blood or other potentially infectious materials.
- Contaminated needles and sharps are not to be recapped or removed unless such action is required by a specific medical procedure. If recapping or needle removal is required, it must be done through the use of a mechanical device (e.g., a hemostat or needle holder) or by a one-handed technique.
- Immediately or as soon as possible after use, contaminated disposable sharps and needles are to be placed in leak-proof, puncture resistant designated sharps containers that are appropriately labeled or color coded. Sharps containers must be conveniently located and accessible to the areas where sharps are being used.
- Eating, drinking, smoking, applying cosmetics or lip balm, and handling contact lenses are prohibited in work areas where there is a reasonable likelihood of occupational exposure.
- 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.
- Specimens of blood or other potentially infectious materials shall be placed in a container which prevents leakage during collection, handling, processing, storage, transport, or shipping. All containers shall be appropriately labeled or color-coded.
- If outside contamination of the primary container occurs, the primary container shall be placed within an appropriately labeled or color-coded second container which prevents leakage during handling, processing, storage, transport, or shipping.
- All procedures involving blood or other potentially infectious materials shall be performed in such a manner as to minimize splashing, spraying, spattering and generation of droplets of these substances.
- Mouth pipetting/suctioning of blood or other potentially infectious materials is prohibited.
- Equipment which may become contaminated with blood or other potentially infectious materials shall be examined prior to servicing or shipping and shall be decontaminated as necessary. If it is not feasible to decontaminate the equipment, a readily observable biohazard label shall be attached to the equipment stating which portions remain contaminated.
- Properly chosen, maintained and exhausted ventilation equipment shall be used during procedures which could cause aerosols of the infectious materials.
- UW - La Crosse personnel who organize blood drives must inform the organization conducting the blood drive, in writing, of their necessity to comply with Bloodborne Pathogen Standards specified in reference 1. Additional requirements are as follows: a) Rooms in which blood drives are conducted should have a tile floor or other impermeable flooring surface. b) The room in which a blood drive is conducted must be cleaned by personnel from the organization conducting the blood drive or custodial staff identified in Section I. c) The organization conducting the blood drive must remove and properly dispose of all potentially infectious waste materials they have generated. d) The organization conducting the blood drive must follow reasonable engineering and work practice controls to limit the likelihood of exposure.
Since the above engineering and work practice controls do not account for every conceivable method to minimize exposures, some Departments may need to develop specific written guidelines to address unique hazards associated with their laboratory procedures.
V. PERSONAL PROTECTIVE EQUIPMENT (PPE)
The University of Wisconsin - La Crosse will make PPE available, at no cost, to employees who have potential for occupational exposure to bloodborne pathogens.
In the context of exposure control, PPE refers to the following types of items:
- fluid resistant gloves;
- fluid resistant gown or apron;
- face shield or mask;
- eye protection;
- items of clothing that cover other parts of the body (e.g. shoe covers, caps, full body suits, etc.); and
- mouthpieces, resuscitation bags, pocket masks, and other ventilation devices.
There is no substitute for good judgment in deciding which items of PPE to wear in particular settings. At a minimum, protective gloves should be worn in any situation where there is potential for exposure to bloodborne pathogens, including cleaning and removal of contaminated materials or laundry.
Additional items of PPE should be added based upon good judgment and according to the type of job or task being performed. Personnel should utilize the PPE specified by their supervisor and as advised in bloodborne pathogens training. Course Instructors shall inform students of PPE requirements prior to any use of blood or other potentially infectious materials.
UW - La Crosse shall assume that appropriate PPE is used to prevent blood or other potentially infectious materials from contacting skin, eyes, mouth, other mucous membranes, or clothing. Where an employee under rare and extraordinary conditions exercises their professional judgment that the use of PPE would have prevented the delivery of health care or would have posed an increased risk to any individual, the event shall be reported to Human Resources. An investigation shall be conducted and documented in order to determine whether changes can be instituted to prevent such occurrences in the future.
All campus locations with personnel that have a chance of exposure to blood or other potentially infectious materials shall have a readily visible supply of gloves and other PPE available. Professional judgment of area personnel should be utilized to determine which items of PPE to wear in particular settings. Such locations shall also have emergency response kits readily available. The Health Center should have mouthpieces, resuscitation bags, pocket masks, or other ventilation devices available.
All emergency response kits shall include:
- fluid resistant gloves and gown or apron;
- masks that cover the oral cavity and nose;
- safety glasses with side shields; goggles or face shield; and
- additional PPE and other supplies available for cleaning, decontamination and disposal of the potentially infectious materials.
Personnel who are required and properly trained to provide ventilatory assistance should have some type of ventilatory or CPR mask in their emergency response kits.
Emergency response kits, PPE and other program implementation supplies are available for purchase through Campus Stores.
Disposal of PPE
Most items of PPE, especially gloves, will be designed to be single use items and shall be discarded after use and before leaving the work area. Disposable clothing is recommended for all areas that have minimal use of clothing. Refer to section VII for cleaning instructions for non-disposable clothing. If an item of PPE becomes excessively soiled during use, it shall be removed and disposed into a designated biohazard waste container or laundry bag. The user shall then wash their hands prior to putting on clean equipment.
PPE that is not designed for disposal (e.g. goggles, safety glasses) should be disinfected in a freshly prepared 10% household bleach in water solution, rinsed and allowed to air dry prior to re-use. PPE should not be cleaned with alcohol, autoclaved or exposed to other cleaning methods which may damage the equipment.
All facilities which use blood and other potentially infectious materials are to be maintained in a clean and sanitary condition. All equipment and working surfaces shall be cleaned and decontaminated after contact with blood or other potentially infectious materials.
All personnel identified as having occupational exposure are responsible for housekeeping duties in their work area. Custodial Staff will perform housekeeping responsibilities in common area's and support cleaning activities in other area's.
Decontamination should, to the extent feasible, be conducted with disposable cleaning supplies. All disposable cleaning supplies and other contaminated items should be discarded in color-coded or labeled infectious waste receptacles. An adequate supply of waste receptacles should be placed in each area were infectious waste is normally generated. When proper waste receptacles are not available in the area, as in the case of medical emergencies, the waste should be retained by the generator in a secure location. The generator shall notify Environmental Health and Safety that the material needs to be disposed. Non-disposable cleaning supplies should be decontaminated after use.
Contaminated work surfaces shall be decontaminated with an appropriate disinfectant after completion of procedures; immediately or as soon as feasible when surfaces are overtly contaminated; after any spill of blood or other potentially infectious materials; and, at the end of the work shift if the surface may have become contaminated since the last cleaning. Appropriate disinfectant includes a freshly prepared 10% household bleach solution in water or other EPA registered disinfectants.
Cleaning of the Campus Health Center shall be performed in accordance with the routine custodial cleaning schedule. Since the building in which the Health Center is located is used by a variety of occupants, the schedule varies depending upon occupant and building requirements.
All bins, pails, cans, and similar receptacles intended for re-use, which have a reasonable likelihood for becoming contaminated with blood or other potentially infectious materials, shall be periodically inspected and decontaminated. Such receptacles shall be cleaned and decontaminated immediately or as soon as feasible upon visible contamination.
Broken glassware shall not be picked up directly with the hands. It should be cleaned up using mechanical means, such as a brush and dust pan, tongs, or forceps. Contaminated broken glassware should be placed in a biohazard sharps container. Other broken glassware should be placed in a puncture resistant container.
Employees are not to reach by hand into containers where contaminated sharps have been placed.
VI. REGULATED WASTE
All blood and other potentially infectious regulated waste materials are to be placed in durable leak-proof containers that are appropriately color-coded or labeled. As feasible, all containers should be autoclaved prior to disposal. Containers that will be autoclaved should have an indicator strip placed on the container prior to autoclaving. Autoclaved containers should be over-packed in sealable containers that are opaque to the inner containers. These containers can then be placed in any solid waste trash dumpster.
Containers that are not autoclaved prior to disposal should have no liquid or semi-liquid blood or OPIM. Contact Environmental Health and Safety to coordinate or receive instructions on the appropriate waste disposal methods.
The following discard and containment procedures applies to all locations and personnel that use single-use sharps, other sharps and broken glassware. The procedure also applies to all personnel that are needle dependant for insulin, allergy, or other shots, while on campus. Needle dependant personnel will be offered containers for proper handling of contaminated needles. The Health Center will supply empty containers and dispose of full containers.
- Contaminated sharps shall be discarded immediately or as soon as feasible in single use containers that are: a) closable, b) puncture resistant, c) leak-proof, d) appropriately labeled or color coded, and e) designed with an opening that will not allow easy access of any body part.
- During use, containers for contaminated sharps shall be: a) easily accessible to personnel and located as close as is feasible to the immediate area where sharps are used or can be reasonably anticipated to be found, b) maintained upright throughout use, c) maintained closed when not in use; and d) replaced routinely and not allowed to overfill.
- When moving containers of contaminated sharps from the area of use, the containers shall be: a) closed to prevent spillage or protrusion of contents during handling, storage, transport or shipping; b) if damaged, placed in a secondary container as specified in section A above, if leakage is possible.
The following discard and containment procedures applies to all locations and personnel that generate non-sharps regulated waste.
- Regulated wastes shall be discarded immediately or as soon as feasible in single use containers that are: a) closable, b) leak-proof, and c) appropriately labeled or color coded.
- During use, containers shall be: a) easily accessible to personnel and located as close as is feasible to the immediate area; b) maintained upright throughout use, c) maintained closed when not in use, and d) replaced routinely and not allowed to overfill.
- When moving containers from the area of use, the containers shall be: a) closed to prevent spillage or protrusion of contents during handling, storage, transport or shipping, b) if damaged, placed in a secondary container as specified in section A above, if leakage is possible.
Soiled sanitary napkins and other feminine hygiene products do not have to be treated as a regulated waste. However, the containers for these products shall be lined with a plastic or wax paper bag and the personnel handling the bags should wear suitable gloves.
VII. CONTAMINATED LAUNDRY
Contaminated laundry includes any garments, whether the employer's or employee's, or other laundry spotted with visible blood or other potentially infectious materials.
Contaminated laundry is to be handled as little as possible and with a minimum of agitation. Contaminated laundry shall be bagged or containerized at the location where it was used and shall not be sorted or rinsed in the location of use. Contaminated laundry shall be placed and transported in appropriately labeled or color-coded bags or containers.
Whenever contaminated laundry is wet and presents a reasonable likelihood of soak-through or leakage from the bag or container, the laundry shall be placed and transported in bags or containers which prevent soak-through and/or leakage of fluids to the exterior.
All contaminated laundry must be delivered to a departments designated laundromat in leak-proof bags or containers that are appropriately labeled or color-coded. Facilities that have minimal use of laundry services, not including the Campus Health Center and Health, Physical Education and Recreation Department, are recommended to use disposable clothing.
VIII. HEPATITIS B VACCINATION, POST-EXPOSURE EVALUATION AND FOLLOW-UP
UW - La Crosse, at no cost to the employee, shall make available hepatitis B vaccination to all employees who have occupational exposure. All vaccinations, post-exposure evaluations and follow-ups will be coordinated by the Human Resources Office. Hepatitis B vaccinations will be offered by the Health Center.
All medical evaluations and procedures, including the hepatitis B vaccine and vaccination series and post-exposure evaluation and follow-up, will be performed by or under the supervision of a licensed physician or another licensed healthcare professional. All such actions will be provided according to recommendations of the U.S. Public Health Service current at the time these evaluations and procedures take place. All laboratory tests will be conducted by an accredited laboratory at no cost to the employee.
Hepatitis B Vaccination
The employee shall be offered an opportunity to receive hepatitis B vaccination at the conclusion of the initial bloodborne pathogen exposure avoidance training session. The employee must initially accept or decline the opportunity to accept the vaccination within 10 working days.
If an employee initially declines hepatitis B vaccination but at a later date while still covered under this standard decides to accept the vaccination, UW - La Crosse shall make the vaccination available at that time.
If subsequent recommendations from the U.S. Public Health Service indicate that a "booster" dose of the vaccine is required, such dose will be offered by UW - La Crosse, at no cost, to all employees who have occupational exposure.
Any employee who declines to receive the hepatitis B vaccination for any reason shall sign the appropriate statement of declination that appears on the Information/Authorization Form for Hepatitis Type B Immunization (Appendix B).
IX. POST-EXPOSURE EVALUATION AND FOLLOW-UP
Any employee with occupational exposure who has an exposure incident shall follow the procedures outlined in Appendix C.
Following a report of an exposure incident the University of Wisconsin - La Crosse shall, in coordination with any private or contract healthcare provider, immediately make available to the exposed employee a confidential medical evaluation and follow-up.
X. INFORMATION PROVIDED TO THE HEALTHCARE PROFESSIONAL
The University of Wisconsin - La Crosse Human Resources Office and the healthcare professional evaluating an employee after an exposure incident will coordinate data-sharing consistent with the Bloodborne Pathogens Standard and the Health Information Portability and Accountability Act (HIPAA).
XI. HEALTHCARE PROFESSIONAL'S WRITTEN OPINION
Within 15 days of the completion of the evaluation of an exposed employee, the UW - La Crosse Human Resources Office will assure the employee receives healthcare professional's written opinion containing the below listed information.
- In the case of evaluation of hepatitis B vaccination requirements, a statement regarding the need for vaccination and whether the employee has received such vaccination.
- In the case of post-exposure evaluation and follow-up, a statement limited to the following information: a) that the employee has been informed of the results of the evaluation, b) 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, c) all other findings or diagnoses shall remain confidential and shall not be included in the written report.
The UW La Crosse Human Resources Office in coordination with the UW Office of Safety and Loss Prevention (worker's compensation function) shall maintain in the standard employee medical record an account of any occupational exposure. Such record will include the following:
- name and social security number of the employee;
- 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;
- a copy of all results of examinations, medical testing, and follow-up procedures relating to post-exposure evaluation and follow-up of an exposure incident;
- the employer's copy of the healthcare professional's written opinion; and
- a copy of the information provided to the healthcare professional as described above.
All employee medical records are confidential and are not to be disclosed or reported to any person within or outside of UW - La Crosse without the express written consent of the employee except as may be required by law. These records are to be retained by the University of Wisconsin for at least the duration of employment plus 30 years in accordance with 29 CFR 1910.20.
Employee training records shall be maintained for at least three years from the date on which the training occurs. A copy of all training records should be forwarded to Environmental Health and Safety and Human Resources.
XIII. COMMUNICATION OF HAZARDS TO EMPLOYEES
UW - La Crosse shall ensure that all employees with occupational exposure participate in a training program which will be provided during working hours and at no cost to the employee. Training shall be provided before the time of initial assignment to tasks where occupational exposure may take place and annually thereafter. Personnel will be informed in writing of annual training dates.
If there are modifications of tasks or procedures, or institution of new tasks or procedures that affect the employee's occupational exposure, UW - La Crosse shall provide additional training that addresses these newly created exposures.
The training program shall contain the following elements:
- an accessible copy of 29 CFR 1910.1030 and an explanation of its contents;
- a general explanation of the epidemiology and symptoms of bloodborne diseases;
- an explanation of the modes of transmission of bloodborne pathogens;
- an explanation of UW - La Crosse's exposure control standard and the means by which the employee can obtain a copy of the written standard;
- an explanation of how to recognize tasks and other activities that may involve exposure to blood and other potentially infectious materials;
- an explanation of the use and limitations of methods that will prevent or reduce exposure including appropriate engineering controls, work practices, and personal protective equipment;
- information on the types, proper use, location, removal, handling, decontamination and disposal of personal protective equipment;
- an explanation of the basis for selection of personnel protective equipment;
- information on hepatitis B vaccine, including information on its efficacy, safety, method of administration, the benefits of being vaccinated, and that the vaccine and vaccination will be offered free of charge;
- information on the appropriate actions to take and persons to contact in an emergency involving blood or other potentially infectious materials;
- an explanation of the procedure to follow if an exposure incident occurs, including the method of reporting the incident and the medical follow-up that will be made available;
- information on the post-exposure evaluation and follow-up that the employer is required to provide for the employee following an exposure incident;
- an explanation of any signs, labels or color coding utilized; and
- an opportunity for interactive questions and answers with the person conducting the training session.
The person conducting the training shall be knowledgeable in the subject matter covered by the elements contained in the training program, as it relates to the work-place that the training will address.
Labels and signs
Biohazard warning labels shall be affixed to containers of regulated waste, refrigerators, freezers and contaminated equipment containing blood or other potentially infectious materials, contaminated laundry; and other containers used to store, transport or ship blood or other potentially infectious materials. Red bags or red containers may be substituted for labels.
Individual containers of blood or other potentially infectious materials that are placed in a labeled container during storage, transport, shipment or disposal are exempted from the labeling requirement.
XIV. CONTRACT LABOR
It is UW - La Crosse's policy to have all independent contract service providers handle the compliance requirements for their employees. Purchasing shall ensure that compliance with the OSHA Bloodborne Pathogens Standard is included as a contract requirement whenever contract service or contract labor is procured. UW - La Crosse will work with contract employers to ensure compliance with the Standard.
Students who have a reasonably anticipated exposure to blood or other potentially infectious materials through their involvement with campus sponsored curricula, programs or activities, will be informed of these potential hazards. This policy does not refer to the student acting as a "good Samaritan". To the extent feasible, UW - Lacrosse will take actions to reduce student exposure to bloodborne pathogens.
The student is responsible for determining their acceptance or avoidance of the hazard and circumstances that can result from this decision. If the student determines that the hazard poses an unreasonable risk, the student may, after consultation and agreement with the instructor or other directly affected campus employee, decline to accept the risk without detrimental affect on their grade. However, additional justified assignments may be required to fulfill course-work requirements.
Course instructors, coaches, and other campus employee's who are involved with students that could have an exposure incident should take the following actions.
- Train students, to the level necessary, in the epidemiology and transmissivity of HBV and HIV, methods to reduce exposures, vaccination availability from Health Center, post exposure follow-up, waste handling procedures and appropriate use of PPE. Special emphasis should be placed on financial issues related to exposure prevention and prophylaxis.
- Present required information to the student in the first course session or meeting, and as necessary.
- Insure that students use PPE. All PPE, except for eye protection, will be provided to the student by UW - La Crosse. The minimum level of PPE for students will be gloves and eye protection.
- Take action to eliminate or reduce the use/volume of human blood and other potentially infectious materials. In addition, use less virulent organisms whenever possible.
To allow students to engage in hazardous activities without risk communication, proper training and ensuring the use of appropriate PPE, opens UW-L to liability under legal negligence theories.
Any student who has exposure to blood or other potentially infectious materials should be informed to follow the procedure described in Appendix C-1, Procedures for Students Following an Exposure Incident.
Students should be informed that they will not be directly charged for professional healthcare administered by Health Center staff. However, the student will be billed for any medical services provided by private healthcare professionals, which they seek on their own accord. Based upon the potential costs associated with treatment, students may desire to acquire private medical insurance coverage.
When evaluating students who have had an exposure incident the Health Center should make appropriate recommendations based upon their professional judgment and guidelines established by the Centers for Disease Control, for evaluation and post exposure follow-up.
Students who are not employees shall be prohibited from handling contaminated laundry and handling, treatment, or sewering of infectious waste, other than the handling required to immediately containerize an infectious waste generated by their laboratory or academic procedures. Students who are not employees shall be prohibited from the handling of contaminated laundry for University related purposes.
XVI. GOOD SAMARITANS AND VOLUNTEERS
Personnel who volunteer their services to the University should not ordinarily be requested or allowed to conduct any work that could reasonably be anticipated to result in exposure to human blood or other potentially infectious materials. If it is reasonably anticipated that the volunteer may have a potential for an exposure incident, the organization requesting the volunteer should ensure that the individual receives exposure control training, PPE is provided and other necessary actions are taken to minimize or eliminate an exposure incident. The campus organization which accepts the volunteer assistance is responsible for compliance with this policy.
Personnel who respond to incidents involving blood or other potentially infectious materials, that are not identified as having occupational exposure in Section I, Exposure Determination, are treated as "Good Samaritans". A "Good Samaritan" is defined as any individual not covered by this written program that responds to an unexpected emergency in an unofficial capacity.
Any "Good Samaritan" or volunteer who has exposure to blood or other potentially infectious materials should be informed to follow the procedure described in Appendix C-2, Procedures for Volunteers and Good Samaritans Following an Exposure Incident.
Good Samaritans and Volunteers medical costs associated with post exposure evaluation and follow-up will not be covered by this written Bloodborne Pathogens Program.
This written Bloodborne Pathogens Exposure Control Program and its Appendices are effective immediately. All personnel shall fulfill their responsibilities as designated within the written program and appendices.
Written Signature and Date on File in Environmental Health and Safety Office.
1.0 APPLICABLE DOCUMENTS
1.1 29 CFR Part 1910.146 "Permit-Required Confined Spaces"
1.2 ILHR 32, Subchapter VI, "Confined Spaces"
This standard establishes the minimum requirements to be taken when it is required that persons enter UW - La Crosse permit-required confined spaces such as tanks, tunnels, pits, ducts, chambers or utility manholes. Environmental Health and Safety maintains a list of permit required confined spaces identified at UW - La Crosse.
A safe and healthful campus environment shall be provided for all UW - La Crosse employees, students, guests and residents of the community. When engineering or administrative controls will not provide an acceptable level of protection, personal protective equipment will be provided to achieve safe working conditions.
4.1 ACCEPTABLE ENTRY CONDITIONS - conditions that must exist in a permit space to allow entry and to ensure that employees involved with a permit required confined space can safely enter and perform work.
4.2 ATTENDANT - an individual stationed outside the permit required confined space who had specific training and monitors the authorized entrants inside the space.
4.3 AUTHORIZED ENTRANT - employee who is authorized by UW-La Crosse to enter a permit required space.
4.4 BLINDED - absolute closure of a pipe, line, or duct by fastening across its bore a solid plate that completely covers the bore and can withstand the maximum upstream pressure.
4.5 CONFINED SPACE - a space that meets all the following criteria:
- is large enough to bodily enter and perform work;
- has limited means of entry and egress;
- is not designed for continuous employee occupancy; and
- has one of four hazardous characteristics (e.g., - hazardous atmosphere, engulfment, entrapment, or other safety/health hazard).
4.6 ENGULFMENT - surrounding and effective capture of a person by a liquid or finely divided solid substance.
4.7 ENTRY - a persons intentional passing though an opening into a permit required confined space.
4.8 ENTRY PERMIT - written or printed document provided by UW - La Crosse to allow and control entry into a permit space. This document must be returned to the Campus Environmental Health and Safety Office after expiration of the permit.
4.9 ENTRY SUPERVISOR - person responsible for:
- determining if acceptable conditions are present before entering a permit space;
- for authorizing entry;
- overseeing entry operations; and
- terminating entry.
4.10 HAZARDOUS ATMOSPHERE - an atmosphere that may expose employees to the risk of death, incapacitation, impairment of ability to self-rescue, injury, or acute illness.
4.11 IMMEDIATELY DANGEROUS TO LIFE OR HEALTH (IDLH) - any condition that poses an immediate or delayed threat to life or that would cause irreversible adverse health effects or that would interfere with an individual's ability to escape unaided from a permit space.
4.12 ISOLATION - process by which a permit space is removed from service and completely protected against the release of hazardous energy or material into the space.
4.13 LOWER EXPLOSIVE LIMIT (LEL) - the lowest concentration of gas or vapor, expressed in percent by volume in air, that burns or explodes if an ignition source is present at room temperature.
4.14 LINE BREAKING - intentional opening of a pipe, line, or duct that is or has been carrying flammable, corrosive, or toxic material, an inert gas or any fluid at a volume, pressure, or temperature capable of causing death or serious physical harm.
4.15 OXYGEN DEFICIENT ATMOSPHERE - an atmosphere containing less that 19.5% oxygen.
4.16 OXYGEN ENRICHED ATMOSPHERE - an atmosphere containing more than 23.5 % oxygen.
4.17 PERMISSIBLE EXPOSURE LIMIT (PEL) - The airborne concentration of a hazardous material that must not be exceeded over a specified time or instantaneously. This value is established by the Occupational Safety and Health Administration (OSHA).
4.18 PERMIT-REQUIRED CONFINED SPACE - a confined space that has one or more of the following characteristics:
- contains or has a reasonable potential for hazardous atmospheres;
- contains a material that has the potential for engulfment;
- is internally configured so an employee could become trapped or asphyxiated by inwardly converging walls or a floor that slopes downward into a smaller cross-section; or
- contains any other recognized serious safety or health hazard.
4.19 PROHIBITED CONDITION - any condition in a permit space that is not allowed by the permit during the period when entry is authorized.
4.20 RESCUE SERVICE - personnel designated to rescue employees from permit spaces, from now on to mean the City of La Crosse Fire Department.
4.21 RETRIEVAL SYSTEM - equipment used for a non-entry rescue of persons from permit spaces.
4.22 TESTING - process by which hazards that may affect entrants of a permit space are identified and evaluated.
4.23 THRESHOLD LIMIT VALUE (TLV) - The airborne concentration of a hazardous material that must not be exceeded over a specified time or instantaneously. This value is established by the American Conference of Governmental Industrial Hygienists (ACGIH).
4.24 WELDING/CUTTING PERMIT - written authorization to perform operations that can provide a source of ignition (e.g., welding, cutting, burning, or heating) or a hazardous atmosphere.
5.1 Policy and Responsibility
All personnel who are part of an entry team have certain responsibilities as members. All practices established by this standard are expected to be retained and demonstrated by each member of the entry team.
5.2 Confined Space Entry Program
The Confined Space Entry Program consists of procedures to communicate the program requirements to all UW - La Crosse employees, as well as contractors. The program consists of the following elements:
- Confined Space Entry Requirements;
- Confined Space Entry Permit;
- Confined Space Entry Procedures and Techniques;
- Training Requirements for Entry Personnel; and
- Confined Space Rescue Procedures.
5.3 Entry Requirements, Procedures, and Techniques
The purpose of this program is to ensure the proper entry, work practices and exit from confined spaces.
5.3.1 Labeling Requirements
Where possible, each permit-required confined space should be labeled indicating that special precautions must be taken prior to entering the space. The signage for each space will read:
Enter by Permit Only.
Some variation will be allowed as long as the general message is clearly conveyed.
5.3.2 Personnel Requirements and Responsibilities
The following are the requirements for each member of the entry team.
- Know and recognize hazards that may be faced during entry.
- Be aware of behavioral effects of exposure to hazardous atmospheres.
- Maintain accurate counts and means to identify all entrants.
- Remain outside the space unless relieved by another qualified attendant.
- Monitor activities inside and outside space.
- Monitor status of entrants and initiate evacuation if: 1) prohibited conditions are detected; 2) present situation may endanger the entrant; or 3) attendant cannot effectively and safely perform duties.
- Know proper method of summoning rescue services before entry.
- Summon rescue services if needed.
- Establish and maintain a means of communication, via radio or telephone.
- Keep unauthorized persons out of entry space.
- Perform non-entry vertical rescues using a winch.
- Perform no other duties that may distract from the primary duties.
B. AUTHORIZED ENTRANT
- Know and recognize hazards that may be faced during entry.
- Obtain and properly use necessary personal protective equipment.
- Communicate as necessary with the attendant.
- Alert attendant when hazardous conditions are detected, identified or suspected.
- Exit the space immediately whenever: 1) ordered to do so by other members of the entry team; 2) warning signs/symptoms are identified; 3) prohibited conditions are identified; or 4) evacuation alarm is activated.
C. ENTRY SUPERVISOR
- Know and recognize hazards that may be faced during entry.
- Verify that all entries have been made on the permit.
- Verify that tests are completed and procedures and equipment are in place.
- Authorize entry to begin.
- Cancel permit when job is complete or unacceptable conditions arise.
- Know proper method of summoning rescue services before entry.
- Ensure that responsibilities are safely and effectively transferred.
- Ensure entrants have all necessary personal protective equipment.
5.3.3 Atmospheric Requirements Prior to Entry
Before entering, the following atmospheric conditions must be met:
- Oxygen level between 19.5% and 23.5%.
- Flammable gas, vapor, or mist below 10% of its LEL.
- Airborne combustible dusts which exceed their lower flammable limit. This limit is approximated as a condition in which dust obscures vision at a distance of 5 feet.
- Airborne hydrogen sulfide level below 10 parts per million (PPM).
- The lower of airborne hazardous substance concentrations specified as PEL’s or TLV’s.
- Concentrations below what is considered as IDLH.
Entry into a permit-required space will not be allowed if monitoring indicates deficiency in any of these categories. Respirators or a self contained breathing apparatus (SCBA) are not to be used to allow entry into deficient atmospheres. To achieve and maintain a safe atmosphere, it may become necessary to take some action to render the space safe for human occupancy. This may include:
- Isolation - precautions taken to prevent release of material and/or energy into the space. This can be achieved through blinding, blanking, disconnecting, lockout/tagout, or removal of incoming pipes or related energy sources.
- Ventilation - purging, inerting, flushing or otherwise ventilating the space with fresh air. The fresh air will displace the contaminated air allowing for safe entry. This can be accomplished by removing ports and openings or by mechanically ventilating the vessel.
- Verification - conditions within the permit space must remain acceptable throughout the duration of entry. UW-La Crosse will require all employees to wear oxygen/LEL meters while working in permit spaces. Verification may also be accomplished by using instruments or process/procedure knowledge.
- Separation - where there is a possibility of external hazards, the space may require barricades to protect the entrants from falling objects or from unauthorized entry.
5.3.4 Evaluation of the Hazards
Before granting entry, the entry supervisor should be aware of the following possible hazards specific to a particular permit-required confined space.
- Oxygen deficiency.
- Combustible, flammable or explosive atmospheres.
- Toxic gases or vapors.
- Physical hazards: 1. engulfment, 2. internal configuration, 3. moving parts or machinery.
- Corrosive chemicals.
Note: Before entry hazardous atmospheric conditions must be rendered harmless. Residual and physical hazards can be minimized by personal protective equipment. The entry supervisor should contact the Campus Environmental Health and Safety Office with any questions pertaining to entry.
5.3.5 Personal Protective Equipment (PPE)
When physical, chemical and/or biological hazards exist the space should be rendered safe for entry without the use of PPE. If this is not possible, the entry supervisor should make every effort to outfit the entrants with the appropriate gear. Most PPE is available through Campus Stores or the Physical Plant Stock Room. Contact the Campus Environmental Health and Safety Office with questions regarding the use of PPE.
Prior to entry each permit space must be sampled for the following atmospheric conditions in the listed order:
- Oxygen level (must be between 19.5% and 23.5%).
- Lower explosive limit (cannot exceed 10%).
- Hydrogen sulfide (cannot exceed 10 ppm).
- Other toxic gas levels.
Note: Oxygen level is sampled first because most combustible gas meters are oxygen dependent. Monitoring in an oxygen deficient atmosphere may result in erroneous readings. Combustible gases are sampled next because the threat of fire or explosion is both more immediate and more life threatening.
All initial monitoring will be done by the Campus Environmental Health and Safety Office. Sufficient advance notice should be given for monitoring to be performed. The Attendant, Authorized Entrant or Entry Supervisor will conduct continuous monitoring for oxygen, LEL and hydrogen sulfide throughout the entry.
A list of current monitoring equipment can be found in Appendix B, the UW-La Crosse Confined Space Entry Permit. All units are required to be calibrated every six (6) months. The calibration will be done by the Campus Environmental Health and Safety Office.
Each entry team is required to establish and maintain communication with its members during the course of work. In instances where distance or surrounding noise prohibit visual or audible communication, two-way radios will be used. Radio or telephone communication must be readily available to the attendant for emergencies. The attendant is responsible for establishing and maintaining a means of communication, via radio, telephone, or cellular telephone (for contractors).
5.3.8 Multiple Entrants
Multiple entrants may enter using the same attendant as long as the following conditions are met.
- All entrants are working on the same project.
- Visual or audible contact is maintained between entrants and attendant.
- For UW-La Crosse supervised entries involving UW - La Crosse employees and contractors, the attendant must be an employee of UW-La Crosse.
- All parties involved are from the same company or have the same supervisor. For example, UW-La Crosse employees will not serve as attendants for multiple turnkey contractor entry teams and vice versa.
Communication equipment only needs to be given to one entrant. However, if the entrants are at distances greater than what would allow for clear communication, the equipment will be provided to multiple entrants. This decision must be made by the entry supervisor before the commencement of work.
5.3.9 Authorization for Entry
Prior to entry, the entry team is required to notify Protective Services as to the location, time of entry, and number of personnel entering the permit-required space. The entry team must notify Protective Services when entry activities are complete.
5.3.10 Confined Space Permit Procedures
Confined space entry permits (see Attachment B) are required for entering any permit-required confined space. To obtain a permit, the entry supervisor must first confirm that work cannot be accomplished without entering the space. If work requires entry, a permit will be completed by the entry supervisor and the Campus Environmental Health and Safety office.
The entry supervisor must make all determinations regarding the safe entry into the space. The entry supervisor, following all requirements set forth in 5.3.2, will grant or refuse entry into the space after reviewing the monitoring results.
If entry is granted the completed permit will be posted or otherwise made readily accessible to all authorized entrants. All authorized entrants will review the permit, review rescue procedures and don any personal protective equipment before entering the space. The entry team will contact Protective Services before entering the space.
Permits are only valid up to eight (8) hours. Some exceptions may be granted with specific approval from the Campus Environmental Health and Safety Office.
The entry supervisor is required to terminate an entry or cancel the permit when the job is complete or a prohibited condition arises in the work area. Upon termination/cancellation, Protective Services must be notified that the entry team(s) has emerged from the space. The permit can then be mailed or delivered to the Campus Environmental Health and Safety Office. All permits will be retained for one (1) year.
5.3.11 Working in Streets
Work in confined spaces with entry from a street may proceed as long as the following conditions are met.
- An entry teams vehicle beacon light and/or four-way hazard flashers shall be activated upon arrival at the entrance to the confined space.
- An entry teams vehicle shall be parked in such a manner to not obstruct traffic, yet provide protection for the employees.
- Vehicle used by entry personnel shall be parked so that its exhaust does not enter the confined space.
- Traffic safety vests shall be worn.
- Easily visible traffic safety cones shall be placed around the entry team vehicle and manhole.
- A flag person should be added to the entry team if traffic flow is inhibited or based on the judgement of the entry supervisor. The flag person will not be the attendant.
5.3.12 Training Requirements for Confined Space Entry
Training will be provided to all employees who must enter confined spaces. Each employee will be provided with the understanding, knowledge, and skills necessary to carry out their duties as well as the functions of this program. Each employee will be trained in all aspects of entry responsibilities, including those of the attendant, entrant, and entry supervisor.
Initial training will be provided by the Campus Environmental Health and Safety Office. Refresher training will be performed by the employee's supervisor or designee. The training packet is available in the Campus Environmental Health and Safety Office on a check-out basis. Refresher training must be conducted under the following circumstances. When there is a change in permit space operations that presents a hazard about which an employee has not previously been trained. In addition, whenever the employer has reason to believe either that there are deviations from the permit space entry procedures or that there are inadequacies in the employee's knowledge or use of these procedures.
5.3.13 Confined Space Rescue
Rescue services will be provided by the La Crosse Fire Department. Protective Services will contact the La Crosse Fire Department to initiate the rescue procedure. Protective Services should be contacted via radio or telephone.
To facilitate rescue a full body harness and retrieval lines will be used for all entries where the use of such equipment does not create other potential hazards. Each member of the team will be trained in the proper operation of this piece of equipment.
In case of an emergency, the attendant will notify Protective Services and have information regarding the confined space readily available. This information includes, but is not limited to: time mishap occurred, number of affected entrants, possible hazards of the space, location and configuration of the space. If the entrant was working with a particular substance for which Material Safety Data Sheets (MSDS) were required, the MSDS must be made available to the treating health care professionals.
5.3.14 Contractor Coordination
All turnkey contract jobs requiring confined space entry will require submittal of the contractor's confined space entry plan before the commencement of work. All regulatory requirements of 1910.146 "Permit-Required Confined Spaces" will be followed by the contractor. The contractor must furnish all equipment required for entry.
As applicable, the Project Manager will inform the contractor of the UW-La Crosse Confined Space Entry Program and its requirements. Contractors are responsible for following all requirements set forth in this document. If any work requires the contractor's personnel to enter permit-required spaces, the contractor is required to obtain permits before entry. The Project Manager will inform the contractor of the hazards posed by the space and any notable experience with the space.
In instances where both UW-La Crosse employees and contractors are serving as entrants, UW-La Crosse will perform all duties prior to entry. In addition, UW-La Crosse will furnish communication equipment and personnel to serve as attendant and entry supervisor.
After completing all work in the confined space the project manager will debrief the contractor regarding the entry and identify any hazards encountered or created during the job. Details of any problems will be forwarded to the Campus Environmental Health and Safety Office.
5.3.15 Annual Review of Confined Spaces
The UW-La Crosse Confined Space Entry Program will be reviewed annually to determine its effectiveness. Utilizing canceled permits and other available information the Campus Environmental Health and Safety office will determine if:
- additional hazards have been identified within a given space;
- additional measures should be taken to protect the entrants;
- additional spaces should be included within the program; and
- some locations can be removed from the program.
The Confined Space Entry Standard is effective immediately. All University of Wisconsin-La Crosse employees shall fulfill their responsibilities as designated within this written standard.
ORIGINAL: May 4, 1994
LAST UPDATED: October 13, 2009
Purpose and scope:
To establish a uniform standard for the use of fall protection equipment when work assignments expose University of Wisconsin - La Crosse (UW-L) employees to conditions which could cause falls resulting in occupational injury or death.
A safe and healthful working environment must be provided for all UW-L employees. When engineering or administrative controls will not provide an acceptable level of protection, protective equipment will be provided to achieve safe working conditions. When fall protection equipment is necessary, the requirements of this standard shall be followed.
As feasible, all operations from which there is a drop of more than 4 feet shall be guarded by rail, picket fence, half door or equivalent barrier. Barrier design criteria are established in Occupational Safety and Health Administration (OSHA) regulation 29 CFR 1910.23. Ladders under 20 feet are exempted from this requirement. Where barriers are not feasible for work at elevated heights (greater than 4 feet) fall protection equipment shall be used.
Personal Protective Equipment:
Personal Protective Equipment (PPE) requirements for fall protection vary depending upon tasks being conducted. Since limited elevated work activities exist at the UW-L, PPE requirements are established based upon specific tasks. If tasks are not identified below, the individual required to work at an elevated height shall receive approval from their supervisor and the Environmental Health and Safety Department prior to proceeding.
Each worker must be protected by a type 1 full-body harness attached to a shock absorbing lanyard. The lanyard must not exceed 6 foot in length and shall be securely attached to substantial members of the structure (not the scaffold), or to securely rigged lines, which will safely suspend the worker in case of a fall.
Elevated work platforms:
Each worker must be protected by a type 1 full-body harness attached to a shock absorbing lanyard. The lanyard must not exceed 6 feet in length and shall be securely attached to substantial members of the platform which will safely suspend the worker in case of a fall. Fall protection equipment must meet design requirements specified in Appendix C, Section I of OSHA regulation 29 CFR 1910.66.
Each worker must be protected by a type 1 full-body harness attached to a shock absorbing lanyard whenever performing materials handling or maintenance operations closer than 6 feet from the edge of a unguarded roof. Similar fall protection is required for inspections or investigations when the individual in closer than 2 feet from the edge of an unguarded roof. The lanyard shall not exceed 6 feet in length and shall prevent travel beyond the edge of the roof. The lanyard shall be securely attached to substantial members of the structure, or to securely rigged lines, which will safely suspend the worker in case of a fall.
Inclement weather, including but not limited to snow, ice, high winds, or rain creates a hazard for all operations conducted on roofs. The employee shall take additional precautions dependant upon the severity of the inclement weather and the task being performed. As necessary the employee should contact their supervisor to review additional precautions. Work shall not be conducted on roofs during lightning storms.
Each worker entering a permit required confined space shall be protected by a type 1 full-body harness, life line and winch capable of retrieving personnel from vertical entries. Additional information on fall protection in permit required confined spaces is included in the written UW-L Confined Space Entry Program.
Additional fall protective equipment use and selection criteria are included in the following list.
- All lifelines and ropes must have a minimum breaking strength of 5,400 pounds.
- All harness and lanyard hardware shall be capable of withstanding a tensile loading of 4000 pounds without cracking, breaking or deforming.
- All equipment subjected to breaking a fall shall be permanently removed from service.
- Lifelines subjected to cutting or abrasion shall be a minimum of 7/8 inch wire core manila rope. All other lifeline applications shall use a minimum of 3/4 inch manila rope or its equivalent.
- Equipment shall only be used for employee safeguarding.
- All lanyards and harnesses shall be purchased.
Two personnel must be present during any high hazard operation requiring use of fall protective equipment.
The safety back-up shall contact Protective Services in case of any incident requiring emergency services.
The employee requiring use of fall protective equipment shall contact their supervisor to discuss and determine if the operation is designated as high hazard.
Components of fall protection equipment must be inspected by a trained, designated individual prior to each use. If, upon inspection, a piece of equipment displays any of the following conditions, that item should be withdrawn from service immediately. Although it is always necessary to consult the manufacturer for specific care instructions, general signs of wear are as follows.
- Cuts or frayed edges
- Mildew or mold
- Undue stretching
- Chemical burns, acids or corrosives
- Corrosion or charring
- Broken stitches
- Inner fiber fuzziness
- Rivets that are loose or distorted
- Tar or similar products that penetrate and harden in the fibers
- Deformed thimbles or enlarged buckle tongue holes or grommets
- Damaged or distorted snap hooks or faulty springs
- Cracks or distortions in fall protection hardware
When ladders are improperly selected, used and maintained they can pose a fall hazard. Requirements to minimize and eliminate such hazards are as follows.
- Only use Type I industrial stepladders of an appropriate length. Do not use makeshift ladders, such as boxes, barrels or chairs or place ladders on such articles for additional height.
- Straight and extension ladders shall have grippers or cleats (safety feet).
- DO NOT select metal ladders when working on or near electrical equipment.
- The distance from the bottom of a straight ladder to its support wall shall be one-quarter the working length of the ladder.
- Set up ladders on a firm level surface.
- Where possible, straight ladders should be secured with a rope or wire at the top and blocked at the bottom.
- The two highest steps and top platform shall not be used for climbing.
- If a straight ladder is used to climb onto an elevated work station, it shall extend at least 3 1/2 feet above the working level.
- Do not over-reach, jump or slide a ladder while on it. Move the ladder as work progresses.
- Always face the ladder and use both hands while ascending or descending.
- Tools or materials should be raised by means of a rope after the climber has reached the working position.
- Barricades and warning signs should be posted when ladders are placed near doors or other locations where they could be struck.
- Two personnel shall handle and set up all extension ladders.
- Ladders should not be used by more than one person at a time.
- Prior to use of a ladder all employees shall inspect the equipment for defects such as missing cleats, cracked rungs, broken spreaders or splinters. Defective ladders must be removed from service and tagged or marked: "Dangerous, Do Not Use".
- Ladders should be stored where they will not be exposed to the weather. Ladders should not be stored near radiators, steam pipes or in places subjected to excessive heat or dampness.
- Do not paint wooden ladders. Clear wood preservative can be used to protect bare wood
The University of Wisconsin - La Crosse shall provide a training program for all employees engaged in work at elevated heights requiring the use of personal protective equipment. The employees shall be trained in the safety procedures to be followed in order to recognize and prevent falls. This training shall include:
- Methods to identify potential fall hazards.
- The function, use, operation, inspection and maintenance of personal protective equipment.
- Procedures to identify and inspect substantial members of the structure, or securely rigged lines, which will safely suspend the worker in case of a fall.
- Alternative administrative or engineering controls that can be used to minimize or eliminate the use of personal fall protection equipment.
As applicable, this training shall include information on the following topics.
- Individuals identified as qualified operators of powered platforms shall be instructed on the operation and inspection of the equipment.
- Individuals required to work on scaffolds shall be instructed on the construction, use and inspection of the equipment.
Individuals required to use fall protection equipment in permit required confined spaces will receive training as outlined in the written UW-L Confined Space Entry Program.
All UW-L personnel required to use ladders shall receive instructions from their supervisor or other designated individual in the proper methods to use, inspect, maintain and store stepladders.
The fall prevention standard is effective immediately. All University of Wisconsin - La Crosse employees shall fulfill their responsibilities as designated within this written standard.
Original: November 12, 1998
Last Updated: October 13, 2009
I. APPLICABLE DOCUMENTS
Occupational Safety and Health Administration, 29 CFR 1910.1200; Hazard Communication.
Wisconsin Department of Commerce, Chapter 32; Public Employee Safety and Health.
Wisconsin Statutes, Section 101.11, Regarding Safe-Place of Employment.
The Hazard Communication Standard (HCS) implemented by the Occupational Safety and Health Administration (OSHA) of the U.S. Department of Labor requires employers to provide information to employees regarding the hazardous chemicals in the workplace and the hazardous properties of these chemicals. This information must be conveyed through a hazard communication program involving labeling, material safety data sheets, employee training, employee access to written records, and a written hazard communication plan.
The HCS applies to any hazardous chemical which is known to be present in the workplace in such a manner that employees may be exposed under normal conditions of use, or in a foreseeable emergency. The definition of “hazardous chemical” under the standard is extremely broad, and includes any chemical which is a physical hazard or a health hazard. The OSHA standard sets a procedure for hazard determination, and any substance determined to be hazardous under this procedure is subject to the program.
This written hazard communication program (HCP) applies to all UW-L employees, students, or building frequenters who may be exposed to hazardous chemicals under normal operating conditions or in foreseeable emergencies. This HCP applies to students and frequenters as stipulated in Wisconsin Statutes, Section 101.11, regarding safe-place of employment. The Wisconsin safe-place statute requires provision of safe physical conditions on the premises. UW-L employees (such as office workers), students, or building frequenters who encounter hazardous chemicals only in non-routine, isolated instances are not covered by the HCS and this HCP.
This standard identifies the policies, procedures, and guidelines for management of the Hazard Communication Program at the University of Wisconsin-La Crosse (UW-L). It was developed to protect UW-L employees, students, and frequenters who use hazardous chemicals at UW-L. The policies set forward in this document are intended to ensure compliance with Federal and State regulatory requirements.
III. SCOPE AND POLICY
A safe and healthful campus environment shall be provided for all UW-L employees, students, guests, and residents of the community. This written HCP requires each Department/Division/Unit to achieve the following minimal standards.
- Take reasonable precautions to provide a campus environment that is free from recognized hazards.
- Ensure that chemical hazards are identified within each work area.
- Make available chemical hazard information to all personnel who may be potentially exposed.
- Rely on MSDS information provided by chemical manufacturers in determining chemicals covered by the provisions of this document.
Chemical - Any element, chemical compound, or mixture of elements and/or compounds. This includes all liquids, gases, alloys, powders, inks, paints, adhesives, and similar materials.
Chemical Name - 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 Chemical Abstracts Service (CAS) rules of nomenclature, or a name which will clearly identify the chemical for the purpose of conducting a hazard evaluation.
Container - Any bag, barrel, bottle, box, can, cylinder, drum, pipe, reaction vessel, storage tank, or vat, or other receptacle that contains a chemical substance.
Employee - An individual in a fiscally compensated (wage/salary) and employed status who may be exposed to hazardous chemicals under normal operating conditions or in foreseeable emergencies. Workers such as office workers who encounter hazardous chemicals only in non-routine, isolated instances are not covered.
Foreseeable Emergency - 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.
Hazardous Chemical- Any chemical which is a physical hazard or a health hazard.
Health Hazard - 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 which act on the hematopoietic system, and agents which damage the lungs, skin, eyes, or mucous membranes.
Immediate Use - 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 that it is transferred.
Label - Any written, printed, or graphic material displayed on or affixed to containers of chemicals.
Material Safety Data Sheet (MSDS) - Written or printed material concerning a hazardous chemical provided by the chemical manufacturer/distributor.
Physical Hazard - A chemical for which there is evidence that it is combustible, a compressed gas, explosive, flammable, an organic peroxide, an oxidizer, pyrophoric, unstable (reactive), or water reactive.
A. Environmental Health and Safety (EH&S) Responsibilities
- Develop and provide overall administrative guidance and supervision for the Hazard Communication Program (HCP), including interpretation of the regulations when clarification is required.
- Provide initial training to University faculty and staff.
- Maintain a file of documentation and records associated with the HCP, including but not limited to:
a. Training records
b. Chemical inventories
c. MSDS (paper copy and electronic database)
B. Department Chair/Manager/Supervisor Responsibilities
- Attend Employee Hazard Communication Program (HCP) training sessions covering the requirements of this program and management responsibilities.
- Ensure that each paid employee using a hazardous chemical in the assigned unit has completed the HCP training and is familiar with the chemicals used in the workplace. (For students see section V.B.10.)
- Ensure that all training is documented.
- Ensure that training is provided to new paid employees at the time of the initial assignment to their area, and whenever the paid employee is reassigned to an area using new or different chemicals and/or processes.
- Provide refresher training whenever new chemical hazards are introduced into the work area.
- Send all training documentation rosters to the Environmental Health and Safety office which identifies the trainer, trainee, course title, and training date.
- Ensure that containers are labeled according to the specifications outlined in Section VI, Labeling.
- Ensure that information and materials for appropriate labeling are provided to the employee.
- Ensure that contract employees and volunteers under their administrative control are informed about hazardous chemicals in the workplace.
- Ensure that department faculty provide and document HCP training for students.
C. Paid Employee Responsibilities
- Attend training seminars on the Hazard Communication Standard.
- Label all containers in accordance with university policy as outlined in Section VI.
- Use safe work practices, protective clothing and equipment required for the job or task.
- Submit the original MSDS for hazardous chemicals to Environmental Health and Safety for inclusion in the site MSDS inventory. A copy may be retained for individual files.
As a minimum, all hazardous chemicals are subject to the labeling requirements of the Hazard Communication Standard (HCS). Each container shall include the chemical or trade name, appropriate hazard warning and manufacturer name. The manufacturer name is not required when a chemical is synthesized on campus.
All containers of hazardous chemicals shall be correctly labeled as described below. The Environmental Health and Safety (EH&S) office will provide container labels for stationary and portable containers upon request.
-Labels and other forms of warning must be legible, in English, and prominently displayed on the container.
-Existing labels on containers shall not be removed or defaced unless re-labeled immediately with the required information.
-Secondary containers (safety cans, plastic bottles, etc.) shall be labeled with the trade and/or chemical name, manufacturer name when not site synthesized, and hazard warnings (health, reactivity, flammability, PPE). The use of unmarked, portable containers of hazardous chemicals is allowed when the material will be immediately used by one person.
-For stationary process containers, regardless of size, alternative identification methods may be used if the hazards of the chemical are effectively conveyed to the employee. Alternate methods of labeling are; signs, placards, and batch tickets (tags). CAS numbering or lettering system may be an acceptable form of identification on the above types of labels. However, all employees must be trained to understand this method of identification and know where to find the applicable MSDS in their work area.
VII. MATERIAL SAFETY DATA SHEETS (MSDS)
The Material Safety Data Sheet (MSDS) is a detailed technical document containing the physical and chemical properties and hazard information about a specific product. In accordance with the HCS, an MSDS is to be prepared by manufacturers and/or distributors of chemical products. MSDS’s for all chemicals and/or chemical mixtures will be provided by chemical manufacturers and/or distributors in accordance with State Procurement Procedures (PRO-D-4). UW-L will rely upon this method of obtaining accurate, complete, and current MSDS’s.
When hazardous chemicals are not purchased through Purchasing Services (e.g., Procurement Card) the individual buying the hazardous chemical shall obtain an MSDS for the product. MSDS acquisition is a requirement of UW-System Purchasing procedures. A copy of all MSDS’s obtained from the manufacturer or distributor should be sent to Environmental Health and Safety (EH&S) for inclusion in the Site Master MSDS file.
Prior to the purchase of a new chemical, it is recommended that a complete and current MSDS be requested. Every new product should be reviewed before being ordered.
A copy of individual MSDS’s for each chemical will be maintained in a master file in the EH&S office. MSDS’s will be made available and accessible during all work shifts. In the event that an MSDS is not available for a chemical used in a particular work area, an MSDS can be requested from the EH&S office.
Supervisors must ensure that employee requests for MSDS’s are promptly handled. The employee must be notified of any delays in responding to an MSDS request. EH&S will forward a copy of the MSDS directly to the employee once it is received from the manufacturer/distributor. Electronic copies of MSDS’s and the Site Chemical Inventory are readily available on a document in the UW-L Environmental Health and Safety Home Page.
A. Job Specific Training and Education
The hazards associated with chemicals used in the work area must be communicated to employees. The UW-L written Hazard Communication Program shall be made available to all employees. Hazard information for chemicals that the employee may come in contact with during their work can be found on the Material Safety Data Sheet (MSDS).
Working with the Environmental Health and Safety (EH&S) Manager, the Department Chair, Manager or Supervisor will be responsible for ensuring employees receive initial training in the Hazard Communication Program. Training will:
- Indicate the location and availability of the written hazard communication program, including the list(s) of hazardous chemicals.
- Explain what an MSDS is, how to read the MSDS (i.e. what each section contains and where to look for specific information), where MSDS’s are kept, and how to obtain a copy of an MSDS.
- Explain the labeling system used at UW-L as outlined in Section VI.
- Encourage employees to familiarize themselves with the chemicals they use. Information should be updated as needed and before the employees work with new chemicals to ensure maximum understanding and employee protection.
- Describe methods and observations that may be used to detect the presence or release of a hazardous chemical.
- Explain what to do in case of a chemical emergency such as a mechanical accident, spill or leak.
- Familiarize employees with caution or other warning signs used in the work area.
- Inform and encourage employees to use any required personal protective equipment and follow safe work practices to protect themselves from hazards.
- Inform employees about the proper performance and possible hazards of any non-routine tasks.
B. Training Documentation
Each paid employee will be asked to sign an employee Training Attendance Roster form during the training session. The original roster should be forwarded to the Environmental Health and Safety Office. A copy should be retained by the trainer.
IX. CONTRACT EMPLOYEES NOTIFICATION
University of Wisconsin - La Crosse personnel who manage contracts with non-university service providers are responsible for instructing all outside contractors to contact the Environmental Health and Safety Office for specific information regarding hazardous chemicals within the University that may pose a risk to contract employees. These same individuals will require all contractors to provide the EH&S Office with information concerning hazardous chemicals brought into any UW-L facility to perform contracted work before that work begins.
The Hazard Communication Program is effective immediately. All University of Wisconsin - La Crosse employees shall fulfill their responsibilities as designated within this written standard.