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OSHA Records

NOTE: This section contains blank forms. Photocopy forms as needed

REC-1

Rev: February 2007

Schedule and Method of Implementation

Of Cal/OSHA Bloodborne Pathogens Standard Requirments

Retain a copy of the blank form. Place completed form after page EC-6 of the Exposure Control Plan.

*Methods include lecture, in-office training, videotapes, etc.

REC-2

Rev: February 2007

Form provided courtesy of Marjorie Maxwell, DDS, Infection Control Consultant

REC-3

Rev: February 2007

Informed Refusal For Hepatitis B Vaccination ­ Confidential

I, ___________________________________ am employed as a _________________________. My employer, _____________________________ , has provided training to me regarding the hepatitis B vaccine. 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 at no charge to me.

______________________________________________________________________________ Signature Date __________________________________________________ Name __________________________________________________ __________________________________________________ __________________________________________________ Address ______________________________________________________________________________ Witness Date

Maintain this record for duration of employment plus 30 years.

Form provided courtesy of Marjorie Maxwell, DDS, Infection Control Consultant

REC-4

Rev: February 2007

Identification, Evaluation and Selection of Engineering and Work Practice Controls

Staff re-evaluates the office's current engineering and work practice controls at least annually and may propose changes to engineering and work practice controls. Sharps with engineered sharps injury protection features may be considered. Suggestions for change may be made at any time. Review Date: ____________________

REC-5

Rev: February 2007

Housekeeping Schedule

FOR THE MONTH OF:__________________

SCHEDULE OF CLEANING: In general, the cleaning schedule is determined by the degree of contamination. The housekeeping tasks will be done as necessary to maintain a safe working environment. In addition to decontaminating contaminated treatment areas between patients, the following cleaning schedule will be maintained.

REC-6

Rev: February 2007

REC-7

Rev: February 2007

REC-8

Rev: February 2007

Individual Training Documentation

I, __________________, certify that I have read and understand the office Exposure Control Plan and have received training as described above. I understand this training and agree to comply with the procedures of the written Exposure Control Plan.

______________________ ______________________ ______________________ _________

Employee Signature Job Title Social Security No. Date

Form provided courtesy of Marjorie Maxwell, DDS, Infection Control Consultant

REC-9

Rev: February 2007

REC-10

Rev: February 2007

Confirmation of Source Patient's Denial for Testing

DATE

TO: FROM:

Source Patient Dr. __________________________________________ __________________________________________ __________________________________________

RE:

Refusal to consent for testing to determine HBV and HIV infectivity

I have informed you regarding the exposure incident that occurred to one of my employees involving your blood or other potentially infectious materials during your dental treatment on ____date_____. By law, and as a responsible employer, I have requested that you consent to testing to determine your HBV, HCV and HIV status. The results of such testing, which shall remain confidential between you and the exposed employee, can substantially reduce the anxiety of the employee regarding the exposure incident. I have previously explained to you the need for and value of your consent for testing in this incident. This letter confirms that you will not grant consent for such testing.

I request that you carefully consider the consequences for the employee of your refusal for testing. If you decide to consent to testing, please contact this office to make arrangements. We will, of course, pay all expenses associated with the testing.

Form provided courtesy of Marjorie Maxwell, D.D.S., Infection Control Consultant

Confidential

REC-11

Rev: February 2007

Employee Informed Refusal of Post-Exposure Medical Evaluation

I, _________________________ , am employed as a ______________________ . My employer, _____________________, has provided training to me regarding infection control and the risk of disease transmission in the dental office.

On ________________________ (date), I was potentially exposed to infectious disease in the office.

Summary of incident: ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________

My employer has offered to provide follow-up medical evaluation and recommended treatment for any infectious disease that I may have contracted as a result of this incident. However, despite my employer's offer, I have elected not to have a medical evaluation. I have personal reasons for making this decision.

______________________________________________________________________________ Signature Date

____________________________________________________ Print Name _______________________________ _______________________________ _______________________________ Address

______________________________________________________________________________ Witness Date

Maintain this record for duration of employment plus 30 years.

Form provided courtesy of Marjorie Maxwell, D.D.S., Infection Control Consultant

REC-12

Rev: February 2007

Checklist for Exposure Follow-Up Requirements

POST-EXPOSURE EVALUATION AND FOLLOW-UP

______ ______ ______

______ ______ ______ ______ ______ ______

Follow Public Health Service guidelines for HIV, HBV and HCV post-exposure protocols. Document routes of exposure and circumstance. Refer exposed employee, if possible within 1-24 hours of exposure incident, to health care provider who will provide U.S. Public Health Service recommended treatment, prophylaxis and counseling. Identify and test source individual, if possible. Do not test source of known HBV and HIV status. Have employee's blood collected and tested or Have blood stored for 90 days to allow for delayed decision to test. Test results are made available to employee. If exposure involves a sharp, Sharps Injury Log is completed within 14 days and Dental Sharps form is updated.

INFORMATION FOR EMPLOYEE'S HEALTH CARE PROVIDER

______

To HBV vaccine provider: Bloodborne Pathogens Standard (CCR 8, GISO 5193).

Provide the following to health care provider evaluating an employee for an exposure incident. ______ ______ ______ ______ Copy of the regulation Bloodborne Pathogens Standard (CCR 8, GISO 5193) Description of employee's job duties during incident Documentation on routes of entry/exposure circumstances. Medical record on employee HBV vaccine.

WRITTEN OPINION OF HEALTH CARE EVALUATOR

______

Is obtained and provided to the employee within 15 days of completion of the evaluation.

Form provided courtesy of Marjorie Maxwell, D.D.S., Infection Control Consultant

REC-13

Rev: February 2007

Written Opinion of Health Care Evaluator

According to the Cal/OSHA Bloodborne Pathogens Standard, a written opinion of the health care provider evaluating and treating an employee for an exposure to infectious agents must be provided to the employee within 15 days of an exposure incident.

Form provided courtesy of Marjorie Maxwell, D.D.S., Infection Control Consultant

REC-14

Rev: February 2007

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