RCUH Policies and Procedures
Table of Contents
1. SAFETY POLICY STATEMENT P.3
2. POLICY ON SAFETY PROGRAM P.4
3. RESPONSIBILITY AND ACCOUNTABILITY OF ALL PERSONNEL P.5
4. DISCIPLINARY ACTION POLICY P.6
5. HAZARD RECOGNITION / SELF-INSPECTION P.6
6. REPORTING AND INVESTIGATING INDUSTRIAL ACCIDENTS P.6-7
7. POLICY ON EDUCATION AND TRAINING P.7-8
8. FIRST AID KITS / TRAINED PERSONNEL P.8
9. VEHICLE USE POLICY P.8-10
10. HAZARD COMMUNICATIONS P.11-13
11. SAMPLE HAZCOM P. 14-17
12. LOCK OUT/TAG OUT P.18-21
13. BLOODBORNE PATHOGENS P.22-38
14. PERSONAL PROTECTIVE EQUIPMENT P.39-41
15. POST-OFFER PHYSICAL EXAMINATIONS P. 42
18. APPENDIX (HIOSH) REGULATIONS
SAFETY POLICY STATEMENT:
The personal safety and health of each and every employee of RESEARCH CORPORATION OF THE UNIVERSITY OF HAWAII (RCUH) is of primary importance. The RCUH Policies 3.930 RCUH Safety and Accident Prevention Program and 3.580 RCUH Workers’ Compensation are the basis of this safety program.
In recognition of the safety and well being of our employees, it shall be this organization’s policy that safety shall not be compromised and will be given precedence over operating productivity whenever necessary.
A comprehensive safety and health program shall be maintained with the objective of reducing the number of accidents and injuries to an absolute minimum. To be successful, such a program must embody the proper attitudes towards accident prevention on the part of both supervisors and employees. It also requires cooperation in all safety and health matters, not only between supervisor and employee, but also between each employee and his or her fellow worker. It is only through cooperation that such programs can work effectively.
The RCUH Human Resources Department will coordinate the safety program. However, Safety is everyone’s responsibility. Principal Investigators, project managers/supervisors and their employees shall be accountable and responsible for an effective safety and accident prevention program. All employees shall adhere to the applicable safety policies, rules, regulations and other provisions relating to their job/project.
Nelson M. Sakamoto
Director of Human Resources
SAFETY PROGRAM POLICY STATEMENT
The RCUH will operate with the intentions of providing a safe and rewarding work environment for its personnel.
a. The RCUH is interested in the personal safety of its employees. It is our policy to provide safe working conditions, require projects to adopt and use safe working methods and make available to employees and require them to use such safety devices as may be necessary and/or advisable.
b. The RCUH Director of Human Resources is responsible for the overall safety program. The Project Safety Coordinator shall be responsible for the coordination and administration of the project’s safety program.
c. It is the policy of RESEARCH CORPORATION OF THE UNIVERSITY OF HAWAII (RCUH) to cooperate in every way with the Hawaii Occupational Safety and Health (HIOSH) and other related agencies that affect our organization.
d. Accident prevention shall be a normal routine operating responsibility of all personnel.
e. Safe work methods and required safety equipment shall be used and supervisors shall be responsible for the enforcement of its usage, including disciplinary actions if necessary.
f. Each RCUH Project will make periodic safety inspections of the operations and shall report the findings to the Director of Human Resources.
RESPONSIBILITY AND ACCOUNTABILITY OF ALL PERSONNEL:
Safety is the responsibility of all personnel at RESEARCH CORPORATION OF THE UNIVERSITY OF HAWAII (RCUH). Each employee is responsible and will be held accountable for his or her personal safety. Specific responsibilities regarding safety will be as follows:
a. PROJECT MANAGEMENT (Principal Investigator):
* Ultimately held responsible for the safety and health of all personnel at his/her project and work locations.
* Will delegate the specific duties of safety to subordinates and hold these subordinates accountable for their respective areas.
* Will require documentation of safety meetings and require continuous updates regarding safety issues.
b. DEPARTMENT MANAGERS/SUPERVISORS/PROJECT MANAGERS/SUPERINTENDENTS:
* Will be held responsible for the actions of their subordinates.
* Will maintain an accident prevention program.
* Will educate and train their employees on safe working procedures.
* Will hold safety meetings with their employees on a periodic basis (more frequently if accidents occur or new safety requirements dictate the need).
* Will document all meetings and related safety issues.
* Will inform their supervisors of safety issues within their work area.
* Will conduct periodic self-inspections of processes and conditions.
* Will perform accident reporting and investigative procedures.
* Will be responsible for administering disciplinary actions.
* Will administer first-aid for minor injuries.
* Will determine if immediate medical attention by a physician is needed when it is warranted.
* Will be responsible for their personal safety while employed.
* Will follow all project rules and regulations regarding safety.
* Will adhere to the accident prevention program of the RCUH and/or Project he/she is assigned to work at.
* Will use proper personal protective equipment when required.
* Will ask questions if uncertain about any issue.
* Will attend all safety related meetings.
* Will immediately report all injuries to their managers/supervisors, no matter how minor it may be.
DISCIPLINARY ACTION POLICY
Each project/program manager/supervisor is responsible to train and educate each employee; it is also the responsibility of each employee to follow all safety rules and regulations while employed.
All managers/supervisors will enforce project safety rules and regulations as outlined in the Safety Program or Project Safety Rules. If disciplinary action is necessary, please follow the RCUH Adverse/Corrective Action Policy (#3.420).
HAZARD RECOGNITION / SELF-INSPECTION:
It is the responsibility of the Principal Investigator, Project Safety Coordinator and/or Project Manager/Supervisor (i.e., responsible project officials) to provide a workplace, which is free of recognizable hazards to their employees, we have adopted this process to achieve this goal. We will conduct “periodic inspections to identify unsafe conditions and work practices and to correct those that are found.”
This Hazard Recognition / Self-Inspection process will allow responsible project officials and the RCUH to provide a safe place of employment for its employees.
The RCUH Director of Human Resources, will administer this process but the inspections will be the responsibility of responsible project official. A checklist inspection form will be used to accomplish this policy.
The original completed copy of the Hazard Recognition / Self-Inspection form will be kept at the project site/department/etc.
All findings will be addressed and corrective actions will be taken to reduce the hazardous exposure.
POLICY ON REPORTING AND INVESTIGATING INDUSTRIAL AND OTHER WORKPLACE ACCIDENTS:
Refer to RCUH Workers’ Compensation Policy (#3.580). This policy will provide administrative guidelines to establish a fringe benefit rate, coordinate claims management, and maintain compliance with Chapter 386, H. R. S.
a. Employees will immediately report all injuries, sustained while on duty, immediately to their manager/supervisor.
b. Supervisors shall be responsible for seeing that injured employees receive immediate medical attention and the details of the incident are reported. Immediately following an injury, the supervisor shall:
(1) Arrange for immediate medical attention and proper transportation to the place of treatment.
(2) Completely fill out the RCUH Supervisor’s Accident Report form. The Supervisor’s Accident Report form must be submitted within 24 hours from the time of injury or notice to the supervisor (whichever is sooner)
c. Start the investigative process to prevent recurrence of the same accident. THIS INCLUDES ALL “NEAR MISS” ACCIDENTS.
d. An official police report or other formal accident investigation agency report must be submitted to the RCUH Director of Human Resources Mobile and/or stationary equipment, motor vehicle, aircraft, or other accidents involving a third-party in which an RCUH employee was injured.
e. When a manager/supervisor is aware of a lost time (disabling injury) accident, he/she shall immediately report the injury to the Human Resources Department of the RCUH and Director of Human Resources.
f. In the event of an industrial death or very serious injury (requiring hospitalization), the project must immediately inform the RCUH Director of Human Resources. As necessary, the RCUH shall inform the Department of Labor and Industrial Relations and the State HIOSH Office.
g. RCUH Project Safety Coordinators shall be responsible for keeping the RCUH Director of Human Resources informed on the status of all accidents. The RCUH Human Resources Department is responsible for the maintenance of industrial accident report records and for administration of industrial injury reports to comply with the law.
POLICY ON SAFETY EDUCATION AND TRAINING:
To increase the safety awareness of our employees, RCUH encourages all projects to provide opportunities for safety education and training. Training may be at the work site (new hire or remedial), or off-site (e.g., seminars). This policy will utilize the following guidelines.
a. RCUH believes in eliminating employee injuries through education and training.
b. Increased employee awareness and knowledge will be continuously stressed by all. All employees will be responsible for their actions while employed by RCUH.
c. The subject matter chosen for these sessions will be based on one or more of the following factors. They are:
* Hazardous exposures as identified relating to the job or task.
* Loss history as indicated through reports.
* Updates or changes in rules, regulations or standards.
* As requested.
* As required.
d. Attendance in mandatory as indicated by management.
e. The information gained through these sessions shall be disseminated to subordinates as required.
f. The actual application of information or knowledge gained during these sessions will be required by all.
FIRST AID KITS / FIRST AID TRAINED PERSONNEL:
It shall be the policy of RCUH to have a first aid kit on hand at areas most accessible to employees and in the proximity of those areas where accidents are most likely to occur. Each site or location will be responsible for keeping the first aid kits adequately supplied.
RCUH requests that all projects and work locations have designated personnel on staff who are trained in first aid. There shall be at least one (1) trained and certified first aid employee on premises, and additional trained/certified first aid personnel based on project operations.
a. A trained and certified first aid person shall be on premises for each shift. The employee shall have the certification certificated on his or her person at all times.
b. Each Project Safety Coordinator will consult the Principal Investigator with recommendations as to the location of the first aid kits. The location of the first aid equipment shall be made known to all employees on premises.
c. Each Project Safety Coordinator will make periodic checks of the first aid equipment at each location.
POLICY GOVERNING THE USE & CONTROL OF PROJECT VEHICLES
(As applicable) this policy shall pertain to all employees, who are authorized an/or assigned the use of a project vehicle, for the benefit of the RCUH or Project the RCUH employee works at. This policy may be superceded by any Project specific policy:
Qualifications: To be eligible to drive a Project vehicle (including pool vehicle) you must:
1) Hold a current valid driver’s license;
2) Have a current Traffic Abstract filed with the Project, which will be review annually by the Project Safety Committee.
Absolutely at no time will the use and control of the Project-owned vehicle be delegated to any one who is not an employee of this Project. It is unauthorized to allow a spouse, family member, friend or anyone else other that an employee of this Project to use, operate and control the Project-owned vehicle. The Project discourages and will assume no responsibility for passengers who are not employees.
Parking violations received while specifically on Project business may be reimbursable, if determined reasonable. All other parking and moving violations are the employee’s responsibility. Any and all moving violations (during working hours) must be reported to the Project immediately, including those received while operation privately-owned vehicles. Any driver receiving three (3) moving violations in any year will be subject to disciplinary action as recommended by the Project Safety Committee.
Alcohol or other substance affecting safe driving:
Absolutely no employee will operate any Project-owned vehicle who has consumed alcoholic beverages or any other substance that may adversely affect the operator’s ability to operate the vehicle in a safe manner.
In case of accidents involving Project-owned vehicles, the employee operating the vehicle shall immediately report such accident to the local Police Department and notify and report to Project’s Principal Investigator or Project’s Safety Coordinator the details of the accident. The employee shall prepare a written and signed report stating the facts and circumstances involving the accident to include but not be limited to the following information: the name, address and phone numbers of those involved and of any witnesses, all pertinent information on the other vehicles and the location of the incident.
At no time shall the employee admit fault until the Project Safety Coordinator reviews the circumstances. In case of injury or death, notify the RCUH Human Resources Department immediately by telephone.
Care and Maintenance
The driver of the Project-owned vehicle shall be responsible for the safe and proper operation of the vehicle. If a vehicle requires maintenance and/or repairs, the driver shall complete a Vehicle Repair Request form (if none is available a hand written note describing the vehicle’s problems) which should be left on the dashboard and said vehicle shall be left with the Project’s Safety Coordinator (or designated individual) for repairs.
From time to time the Project Safety Coordinator (or designated individual) will be required to do safety inspections and/or preventive maintenance on Project vehicles. Every attempt will be made so as to cause the least inconvenience.
A driver who is assigned a specific vehicle is responsible to keep it clean at all times and in proper/safe working condition.
Safety & Accident Investigation Committee
(As applicable) the Safety & Accident Investigation Committee shall be comprised of a panel of individuals appointed by the Principal Investigator who will monitor, develop and implement safety rules and regulations. The Committee is responsible for reviewing and recommending all disciplinary actions on any vehicle related accidents.
This policy shall take effect immediately and may from time to time be revised. All revisions, as recommended and adopted by Management, shall be made a part to this policy as if said revisions are fully written hereunder.
Hawaii Driver’s Abstract
Good fleet management prescribes annual review of driving records for all employees who drive on behalf of the project. These records are available by mail and take approximately 6-8 weeks.
An acceptable request format must include all the information as noted. Request must show full name, date of birth, address and operator’s license number (same as Social Security number). It is NOT necessary for anyone who requests a driver’s record to file proof that he has permission from the driver to obtain a copy of the drivers’ record.
Drivers’ records, etc., are available for a $2.00 abstract fee at the following locations:
District Court District Court of the Second Circuit
1111 Alakea Street State of Hawaii
Honolulu, HI 96813 Violations Bureau
2145 Main Street
Wailuku, Maui, HI 96793
District Court of the Third Circuit District Court of the Fifth Circuit
State of Hawaii State of Hawaii
Violations Bureau Violations Bureau
P.O. Box 896 P.O. Box 1895
Hilo, HI 96720 Lihue, Kauai, HI 96766
HAZARD COMMUNICATION PROGRAM
The RCUH has implemented a Hazard Communication Program, to minimize the risk of hazardous materials to our employees.
We provide information about chemical hazards and other hazardous substances, in the control of hazards via our Hazard Communication Program which includes container labeling, Material Safety Data Sheets (MSDS) and training employees on the hazards and controls while using hazardous materials.
1) CONTAINER LABELING:
It is the policy of RCUH that containers of hazardous substances will not be released for use until the following labeling information is verified:
A) Containers labeled to its contents.
B) Appropriate hazard warnings.
C) The name and address of the manufacturer.
D) The responsibility is assigned to the Project’s Safety Coordinator.
To further ensure that employees are aware of the hazards of the materials used in their work area, it is our practice to label all secondary containers. The Supervisor in each department will ensure that all secondary containers are labeled with either an extra copy of the original manufacturer’s label or with generic labels which identify the contents and hazard warning.
2) MATERIAL SAFETY DATA SHEETS (MSDS)
A master file of MSDS for all hazardous substances to which employees of this project may be exposed are kept at Principal Investigator’s office or the Project’s Safety Coordinator’s office. Project’s Safety Coordinator is responsible for obtaining MSDS for the project for maintaining the MSDS file.
MSDS’s are reviewed for completeness by RCUH Director of Human Resources (or Project Safety Coordinators if they are qualified to do so). If an MSDS is missing or obviously incomplete, a new MSDS will be requested from the manufacturer or vendor. HIOSH will be notified if a complete MSDS is not received. MSDS’s are available to all employees in their work area for review during each work shift. Employees are to contact their supervisor or Project Safety Coordinator immediately if MSDS’s are not available or new hazardous substance(s) in use do not have MSDS.
3) EMPLOYEE INFORMATION AND TRAINING
Employees will, as part of their orientation, receive information on the following:
A) Summary of the OSHA Hazard Communication Regulation, including their rights under the Regulation.
B) Where hazardous substances are present.
C) Location of the Written Hazard Communication Program.
D) Physical & Health effects of the substances, signs and symptoms of overexposure.
E) How to lessen or prevent over exposure to these hazardous substances.
F) Steps the project has taken to lessen or prevent exposure to these substances.
G) First Aid procedures to follow if employees are exposed to hazardous substance(s).
H) How to read labels and review MSDS’s to obtain appropriate hazard information.
*NOTE: It is critically important that all of our employees understand the training. When new hazardous substances are introduced supervisors will review the above items as they are related to the new material.
4) HAZARDOUS NON-ROUTINE TASK
Periodically, employees may be required to perform hazardous non-routine tasks. Each affected employee will be given information by their supervisor about hazards to which they may be exposed during such activity.
This information will include:
A) Specific hazards, related to non-routine tasks.
B) Protective/safety measures which are required.
C) Measures the project has taken to lessen the hazards including ventilation, respirators, presence of another employee and emergency procedures.
5) HAZARD SUBSTANCES IN UNLABELED PIPES
To ensure that our employees who work on unlabeled pipes have been informed as to the hazardous substances contained within, the following policy has been established:
Prior to starting work on unlabeled pipes, employees are to contact the maintenance supervisor for the following information:
A) The hazardous substances in the pipe.
B) Potential hazards.
C) Controls over the hazards.
6) INFORMING CONTRACTORS
To ensure that outside contractors work safely in our plant, it is the responsibility of to provide the contractor the following information:
A) Hazardous substances to which they may be exposed while on the job site.
B) Precautions the employees may take to lessen the possibility of exposure by usage of appropriate personal protective devices.
If anyone has questions about this plan, contact the department supervisor.
Our plan will be monitored by our Project Safety Coordinator to ensure that the policies are carried out and that the plan is effective.
PROJECT HAZARD COMMUNICATION PROGRAM
OSHA requires every employer using or producing hazardous chemicals to develop and implement a written hazard communication program that includes provisions for container labeling, Material Safety Data Sheets and an employee training program. The program must include a listing of the hazardous chemicals in each work area, the means the employer will use to inform employees of job hazards (including non-routine tasks), the hazards associated with chemicals in unlabeled pipes, and the way the employer will inform contractors of the hazards to which their employee may be exposed.
The following program is only an example. Employers are encouraged to develop their own program specifically tailored to their operation and needs. It does not have to be lengthy or complicated. The written program must be available to employees, their designated representatives and OSHA.
_________________has implemented a Hazard Communication Program to minimize the risk of hazardous materials to our employees.
As a project, we provide information about chemical hazards, and the control of hazards via our Hazard Communication Program. This program will include container labeling, Material Safety Data Sheets (MSDS) and training employees on the hazards and controls while using hazardous materials.
A. CONTAINER LABELING
It is the policy of ____________________that containers of hazardous substances will not be released for use until the following label information is verified:
1 Containers are labeled as to the contents
2 Appropriate hazard warnings
3 The name and address of the manufacturer
The responsibility is assigned to
To further ensure that employees are aware of the hazards of materials used in their work areas, it is our practice to label all secondary containers. The supervisor in each department will ensure that all secondary containers are labeled with either an extra copy of the original manufacturer’s label or with generic labels, which have a block for identity and blocks for the hazard warning.
MATERIAL SAFETY DATA SHEETS (MSDS)
Copies of MSDS for all hazardous substances to which employees of this project may be exposed are kept in the project’s administration office for the hazardous materials being used in their respective areas.
The Project Safety Coordinator is responsible for obtaining and maintaining all MSDS for the project.
The Project Safety Coordinator reviews material Safety Data Sheets for completeness.
If an MSDS is missing or obviously incomplete, a new MSDS will be requested from the manufacturer. OSHA will be notified if a complete MSDS is not received.
Material Safety Data Sheets are available to all employees in their work area for review during each work shift. If MSDS is not available or new hazardous substance(s) in use do not have MSDS, contact the Project Safety Coordinator immediately.
C. EMPLOYEE INFORMATION AND TRAINING
Employees will, as part of their orientation, receive information on the following:
1. A summary of the OSHA Hazard Communication Regulation, including their rights under the Regulation.
2. Where hazardous substances are present.
3. Location of the written hazard communication program.
4. Physical and health effects of the hazardous substances.
5. How to lessen or prevent exposure to these hazardous substances.
6. Steps that have been taken to lessen or prevent exposure to these substances.
7. First aid procedures to follow if employees are exposed to hazardous substances(s).
8. How to read labels and review MSDS to obtain appropriate hazard information.
NOTE: It is critically important that all of our employees understand the training. If you have any additional questions, please contact the Project’s Safety Coordinator or the RCUH Director of Human Resources.
When new hazardous substances are introduced, supervisors will review the above items as they are related to the new material.
D. HAZARDOUS NON-ROUTINE TASKS
Periodically, employees may be required to perform hazardous non-routine tasks. Each affected employee will be given information by their supervisor about hazards to which they may be exposed during such an activity. This information will include:
1. Specific hazards, related to non-routine tasks.
2. Protective/safety measures which are required.
3. Measures the project has taken to lessen the hazards including ventilation, respirators, presence of another employee and emergency procedures.
The following is a list of non-routine tasks performed by employees of
Tasks Hazardous Substances
E. HAZARDOUS SUBSTANCES IN UNLABELED PIPES
To ensure that our employees who work on unlabeled pipes have been informed as to the hazardous substances contained within, the following policy has been established:
Prior to starting work on unlabeled pipes, employees are to contact the maintenance supervisor for the following information:
1. The hazardous substance in the pipe
2. Potential hazards
F. INFORMING CONTRACTORS
To ensure that outside contractors work safely in our plant, it is the responsibility of__________________________.
to provide contractors the following information:
1. Hazardous substances to which they may be exposed while on the job site.
2. Precautions the employees may take to lessen the possibility of exposure by usage of appropriate protective measures.
If anyone has questions about this plan, contact the Project Safety Coordinator to ensure that the policies are carried out and that the plan is effective.
Principal Investigator Project Safety Coordinator
G. LIST OF HAZARDOUS SUBSTANCES
The following is a list of all known hazardous substances present at
Specific information on each noted hazardous substance(s) can be obtained by reviewing the Material Safety Data Sheets.
Tasks Hazardous Substances
Keep in mind that the Written Hazard Communication Program is only a step in complying with the Hazard Communication Standard. For more information and assistance in complying with state right-to-know law and OSHA Hazard Communication standard, please contact the Risk Control Representative at your local Industrial Indemnity office..
This procedure establishes the minimum requirements for the Lockout or Tagout of energy isolating devices. It shall be used to ensure that the machinery/equipment are isolated from all potentially hazardous energy, and locked out or tagged out before employees perform any servicing or maintenance activities where the unexpected energization, start up or release of stored energy could cause injury to employees.
The Project Safety Coordinator is responsible for the compliance of the procedure and will provide training for each supervisor.
The supervisor of each area/department will provide training for affected employees in their area of responsibility.
Employees shall be instructed in the safety significance of the lockout/tagout procedure. Each new or transferred employee will be instructed in the specific lockout/tagout procedure for their department, or equipment.
Whenever outside servicing personnel are to be engaged in activities requiring equipment installations, repairs or construction, the affected supervisor shall review the lockout/tagout procedure with the outside contractor or non-employee.
The lockout/tagout procedures shall be reviewed to ensure they conform to the current standard used. It shall be a condition of employment for all outside contractors/non-employees to abide by the project’s lockout/tagout procedure.
All employee’s of Project’s designated staff (applicable to specific type of operations) shall be considered authorized employees for the purposes of implementation of the lockout/tagout procedure.
The lockout boards are to be located at each motor control station.
LOCKS, HASPS and “DO NOT OPERATE” TAGS:
Each lock when not in use shall be stored on the LOCKOUT BOARD with the hasp and key and “Do Not Operate” tag.
Each employee who initiates the lockout is responsible for the lock hasp and key. NO employee may use any other lock other than those provided by the project.
It shall be a condition of employment at the RCUH (and Project work locations), that the following sequence be followed.
1) The person(s) initiating the lockout shall notify the affected employees of the equipment to be locked out.
The person(s) locking out the equipment, shall be familiar with the location of the energy source.
The employee placing the lock on the control source shall place a “DO NOT OPERATE” tag on the hasp and write their name on the back of the tag (grease pens are located next to the lockout board).
If more than one person is involved in repairing the machinery, each person shall add THEIR OWN lock and tag to the hasp. (Project approved lock)
2) If the machine or equipment is operating, use normal shut down procedures.
3) Stored energy (such as that in springs, elevated machine members, rotating flywheels, hydraulic systems, air, gas, steam, or water pressure, etc) must be dissipated or restrained by methods such as repositioning, blocking, bleeding down, etc.
4) Lockout the energy source with project approved locks.
5) Test run the machinery to ensure you have locked out the correct source.
* CAUTION: Remember to return the control(s) to the “neutral” or “off” position after the test.
6) The equipment has now been properly locked out and repairs or servicing can begin.
SHIFT OR PERSONNEL CHANGES:
Employees going off shift will transfer the key(s) to the oncoming personnel.
It is the responsibility of the oncoming personnel to ensure proper lockout procedures have been followed.
Discuss the status of repairs and any difficulties encountered.
If repairs are not completed and lock out must be in place over night or weekends during non-occupancy, the maintenance supervisor should be notified either in writing or by phone call.
The key should be left in a drop box in the supervisor’s office.
REMOVAL OF LOCKOUT DEVICES:
1) All tools, blocks or other devices should be removed.
2) All guards or safety equipment shall be reinstalled.
3) Only those who placed the locks on the energy source shall remove them. If the lock and key had been transferred to the oncoming shift, the person(s) completing the work shall remove and store the locks on the lockout board.
In the event the person(s) who applied the lockout device is not available to remove it, that device may be removed under the direction of the supervisor, provided that the following procedure is followed:
A) Verification by the supervisor that the employee who applied the device is not at the facility.
B) Every reasonable effort has been made to locate the employee(s) and to inform them the lock was being removed.
C) The supervisor shall visually inspect the area or machinery.
D) The supervisor will post another employee at the location of the machinery.
E) The supervisor and operator will then remove the lockout device.
5) Normal start up procedures should then be followed.
This procedure has been developed to protect all employees and those who may visit or work at RCUH/Project. We are committed to providing a safe work place and appreciate your cooperation in our safety efforts.
POLICY ENFORCEMENT PROCEDURES
The implementation process has been added to help us evaluate the accuracy of the program and to ensure the proper use of the lock-outs.
The process is being implemented now and should be done while any forms of maintenance or repairs are in progress.
The employees will be informed or trained by their supervisor in each given department. The supervisor should obtain a written sign off from the employee after the training. This record will be kept in the employee’s personal file.
Copies of the training roster will also be kept in the Project Safety Coordinators “Training” file at each facility.
1) Failure to use the lockout during the 30 day transition period will result in a verbal reminder with the affected employee.
2) After the transition period, it will be a condition of employment (i.e., must comply or be subject to disciplinary action including possible discharge).
3) Failure to follow the lockout program can result in disciplinary action up to and including discharge.
4) Supervisors will be responsible for the enforcement of the lockout program.
EXPOSURE CONTROL PLAN
Date of Preparation:
In accordance with the OSHA Bloodborne Pathogens Standard, 29 CFR 1910.1030 the following exposure control plan has been developed:
The purpose of this exposure control plan is to:
1. Eliminate or minimize employee occupational exposure to blood or certain other body fluids;
2. Comply with the OSHA Bloodborne Pathogens Standard, 29 CFR 1910.1030.
B. Exposure Determination
OSHA requires employers to perform an exposure determination concerning which employees may incur occupational exposure to blood or other potentially infectious materials. The exposure determination is made without regard to the use of personal protective equipment (i.e. employees are considered to be exposed even if they wear personal protective equipment). This exposure determination is required to list all job classifications in which all employees may be expected to incur such occupational exposure, regardless of frequency. At this facility the following job classifications are in this category:
(List job titles)
In addition, OSHA requires a listing of job classifications in which some employees may have occupational exposure. Since not all the employees in these categories would be expected to incur exposure to blood or other potentially infectious materials, task or procedures that would cause these employees to have occupational exposure are also required to be listed in order to clearly understand which employees in these categories are considered to have occupational exposure. The job classifications and associated tasks for these categories are as follows (or place in appendix):
C. Implementation Schedule and Methodology
OSHA also requires that this plan include a schedule and method of implementation for the various requirements of the standard. The following complies with this requirement:
1. Compliance Methods
Universal precautions will be observed at this facility in order to prevent contact with blood or other potentially infectious materials. All blood or other potentially infectious material will be considered infectious regardless of the perceived status of the source individual.
Engineering and work practice controls will be utilized to eliminate or minimize exposure to employees at this facility. Where occupational exposure remains after institution of these controls, personal protective equipment shall also be utilized. At this facility the following engineering controls will be utilized: (list controls, such as sharps containers, biosafety cabinets, etc.)
The above controls will be examined and maintained on a regular schedule. The schedule for reviewing the effectiveness of the controls is as follows: (list schedule such as daily, once/week, etc., as well as list who has the responsibility to review the effectiveness of the individual controls, such as the supervision for each department, etc.)
Handwashing facilities shall be made available to the employees who incur exposure to blood or other potentially infectious materials. OSHA requires that these facilities be readily accessible after incurring exposure. (If handwashing facilities are not feasible, the employer is required to provide either an antiseptic cleanser in conjunction with clean cloth/paper towels or antiseptic towelettes). When these alternatives are used, then the hands are to be washed with soap and running water as soon as feasible. Employers who must provide alternatives to readily accessible handwashing facilities should list the location, tasks, and responsibilities to ensure maintenance and accessibility of these alternatives.
(list name of position/person, e.g. supervisors) shall ensure that after the removal of personal protective gloves, employees shall wash hands and any other potentially contaminated skin area immediately or as soon as feasible with soap and water.
(list name of position/person, e.g. supervisors) shall ensure that if employees incur exposure to their skin or mucous membranes, then those areas shall be washed or flushed with water as soon as feasible following contact.
Contaminated needles and other contaminated sharps will not be bent, recapped, removed, sheared or purposely broken. OSHA allows an exception to this if the procedure would require that the contaminated needle be recapped or removed and no alternative is feasible and the action is required by the medical procedure. If such action is required, then the recapping or removal of the needle must be done by the use of a mechanical device or a one-handed technique. At this facility recapping or removal is only permitted for the following procedures: (List the procedures and also list the mechanical device to be used or alternately if a one-handed technique will be used.)
3. Containers for REUSABLE Sharps
Contaminated sharps that are reusable are to be placed immediately, or as soon as possible after use, into appropriate sharps containers. At this facility the sharps containers are puncture resistant, labeled with a biohazard label and are leak proof.
(Employers should list here where reusable sharps containers are located as well as who has responsibility for removing sharps from containers and how often the containers will be checked to remove the sharps.)
4. Work Area Restrictions
In work areas where there is a reasonable likelihood of exposure to blood or other potentially infectious materials, employees are not to eat, drink, apply cosmetics or lip balm, smoke, or handle contact lenses. Food and beverages are not to be kept in refrigerators, freezers, shelves, cabinets, or on counter tops or bench tops where blood or other potentially infectious materials are present.
Mouth pipetting/suctioning of blood or other potentially infectious materials is prohibited.
All procedures will be conducted in a manner which will minimize splashing, spraying, splattering, and generation of droplets of blood or other potentially infectious materials. Methods which will be employed at this facility to accomplish this goal are: (List methods, such as covers on centrifuges, usage of dental dams if appropriate, etc.)
Specimens of blood or other potentially infectious materials will be placed in a container which prevents leakage during the collection, handling, processing, storage, and transport of the specimens.
The container used for this purpose will be labeled or color coded in accordance with the requirements of the OSHA standard. (Employers should note that the standard provides for an exemption for specimens from the labeling/color coding requirement of the standard provided that the facility utilizes universal precautions in the handling of all specimens and the containers are recognizable as containing specimens. This exemption applies only while the specimens remain in the facility. If the employer chooses to use this exemption, then it should be stated here .)
Any specimens which could puncture a primary container will be placed within a secondary container which is puncture resistant.
If outside contamination of the primary container occurs, the primary container shall be placed within a secondary container which prevents leakage during the handling, processing, storage, transport, or shipping of the specimen.
6. Contaminated Equipment
(insert name of position/person) is responsible for ensuring that equipment which has become contaminated with blood or other potentially infectious materials shall be examined prior to servicing or shipping and shall be decontaminated as necessary unless the decontamination of the equipment is not feasible.
7. Personal Protective Equipment
(insert name of position/person) is responsible for ensuring that the following provisions are met.
All personal protective equipment used at this facility will be provided without cost to employees. Personal protective equipment will be chosen based on the anticipated exposure to blood or other potentially infectious materials. The protective equipment will be considered appropriate only if it does not permit blood or other potentially infectious materials to pass through or reach the employees’ clothing, skin, eyes, mouth, or other mucous membranes under normal conditions of use and for the duration of time which the protective equipment will be used. (Indicate how clothing will be provided to employees; e.g., who has responsibility for distribution. You could also list which procedures would require the protective clothing and the recommended type of protection required, this could also be listed as an appendix to this program.)
PPE Use shall ensure that the employee uses appropriate PPE unless the supervisor shows that employee temporarily and briefly declined to use PPE when under rare and extraordinary circumstances, it was the employee’s professional judgment that in the specific instance its use would have prevented the delivery of healthcare or posed an increased hazard to the safety of the worker or co-worker. When the employee makes this judgment, the circumstances shall be investigated and documented in order to determine whether changes can be instituted to prevent such occurrences in the future.
(insert name of position/person) shall ensure that appropriate PPE in the appropriate sizes is readily accessible at the work site or is issued without cost to employees. Hypoallergenic gloves, glove liners, powder less gloves, or other similar alternatives shall be readily accessible to those employees who are allergic to the gloves normally provided.
PPE Cleaning, Laundering and Disposal
All personal protective equipment will be cleaned, laundered, and disposed of by the employer at no cost to the employees. All repairs and replacements will be made by the employer at no cost to employees.
All garments, which are penetrated by blood, shall be removed immediately or as soon as feasible. All PPE will be removed prior to leaving the work area.
When PPE is removed, it shall be placed in an appropriately designated area or container for storage, washing, decontamination or disposal.
Gloves shall be worn where it is reasonably anticipated that employees will have hand contact with blood, other potentially infectious materials, non-intact skin, and mucous membranes; when performing vascular access procedures and when handling or touching contaminated items or surfaces. Disposable gloves used at this facility are not to be washed or decontaminated for re-use and are to be replaced as soon as practical when they become contaminated or as soon as feasible if they are torn, punctured, or when their ability to function as a barrier is compromised. Utility gloves may be decontaminated for re-use provided that the integrity of the glove is not compromised. Utility gloves will be discarded if they are cracked, peeling, torn, punctured, or exhibit other signs of deterioration or when their ability to function as a barrier is compromised.
Eye and Face Protection
Masks in combination with eye protection devices, such as goggles or glasses with solid side shields, or chin length face shields, are required to be worn whenever splashes, sprays, splatters, or droplets of blood or other potentially infectious materials may be generated and eye, nose, or mouth contamination can reasonably be anticipated. Situations at this facility, which would require such protection, are as follows:
Additional clothing (such as lab coats, gowns, aprons, clinic jackets, or similar garments) shall be worn in instances when gross contamination can reasonably be anticipated (such as autopsies and orthopedic surgery). The following situations require that such protective clothing be utilized:
This facility will be cleaned and decontaminated according to the following schedule: (list area and schedule)
Decontamination will be accomplished by utilizing the following materials: (list the materials which will be utilized, such as bleach solutions or EPA registered germicides)
All contaminated work surfaces will be decontaminated after completion of procedures and immediately or as soon as feasible after any spill of blood or other potentially infectious materials, as well as the end of the work shift if the surface may have become contaminated since the last cleaning. (Employers should add in any information concerning the usage of protective coverings, such as plastic wrap, which they may be using to assist in keeping surfaces free of contamination.)
All bins, pails, cans and similar receptacles shall be inspected and decontaminated on a regularly scheduled basis (list frequency and by position/person ).
Any broken glassware, which may be contaminated, will not be picked up directly with the hands.
Reusable sharps that are contaminated with blood or other potentially infectious materials shall not be stored or processed in a manner that requires employees to reach by hand into the containers where these sharps have been placed.
9. Regulated Waste Disposal
Contaminated sharps shall be discarded immediately or as soon as feasible in containers that are closable, puncture resistant, leak proof on sides and bottom and labeled or color coded.
During use, containers for contaminated sharps shall be 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 (e.g., laundries).
The containers shall be maintained upright throughout use and replaced routinely and not be allowed to overfill.
When moving containers of contaminated sharps from the area of use, the containers shall be closed immediately prior to removal or replacement to prevent spillage or protrusion of contents during handling, storage, transport or shipping.
The container shall be placed in a secondary container if leakage of the primary container is possible. The second container shall be closable, constructed to contain all contents and prevent leakage during handling, storage and transport, or shipping. The second container shall be labeled or color coded to identify its contents. Reusable containers shall not be opened, emptied or cleaned manually or in any other manner, which would expose employees to the risk of percutaneous injury.
Other Regulated Waste
Other regulated waste shall be placed in containers, which are closable, constructed to contain all contents and prevent leakage of fluids during handling, storage, transportation or shipping.
The waste must be labeled or color coded and closed prior to removal to prevent spillage or protrusion of contents during handling, storage, transport or shipping.
NOTE: Disposal of all regulated waste shall be in accordance with applicable United States, state and local regulations.
10. Laundry Procedures
Laundry contaminated with blood or other potentially infectious materials will be handled as little as possible. Such laundry will be placed in appropriately marked (biohazard labeled, or color coded red bag) bags at the location where it was used. Such laundry will not be sorted or rinsed in the area of use.
Please note: If your facility utilized Body Substance Isolation or Universal Precautions in the handling of all soiled laundry (i.e., all laundry is assumed to be contaminated), no labeling or color coding is necessary if all employees recognize the hazards associated with the handling of this material.
Laundry at this facility will be cleaned at .
Please note: If your facility ships contaminated laundry off-site to a second facility, which does not utilize Universal Precautions in the handling of all laundry, contaminated laundry must be placed in bags or containers, which are labeled or color-coded. One possible solution would be to include a requirement in the contract laundry scope of work requiring the laundry to utilize the equivalent of Universal Precautions.
11. Hepatitis B Vaccine and Post-Exposure Evaluation and Follow-Up
The (insert project name) shall make available the Hepatitis B vaccine and vaccination series to all employees who have occupational exposure, and post-exposure follow-up to employees who have had an exposure incident.
The (insert position/person) shall ensure that all medical evaluations and procedures including the Hepatitis B vaccine and vaccination series and post-exposure follow-up, including prophylaxis, are:
a) Made available at no cost to the employee;
b) Made available to the employee at a reasonable time and place;
c) Performed by or under the supervision of a licensed physician or by or under the supervision of another licensed healthcare professional; and
d) Provided according to the recommendations of the U.S. Public Health Service.
All laboratory tests shall be conducted by an accredited laboratory at no cost to the employee.
Hepatitis B Vaccination
(insert name of position/person) is in charge of the Hepatitis B vaccination program. (Where appropriate: We contract with to provide this service.)
Hepatitis B vaccination shall be made available after the employee has received the training in occupational exposure (see Section 13, “Information and Training”) and within 10 working days of initial assignment to all employees who have occupational exposure unless the employee has previously received the complete Hepatitis B vaccination series, antibody testing has revealed that the employee is immune, or the vaccine is contraindicate for medical reasons.
Participation in a pre-screening program shall not be a prerequisite for receiving Hepatitis B vaccination.
If the employee initially declines Hepatitis B vaccination but at a later date while still covered under the standard decides to accept the vaccination, the vaccination shall then be made available.
All employees who decline the Hepatitis B vaccination offered shall sign the OSHA required waiver indicating their refusal.
If a routine booster dose of Hepatitis B vaccine is recommended by the U.S. Public Health Service at a future date, such booster doses shall be made available.
Post-Exposure Evaluation and Follow-up
All exposure incidents shall be reported, investigated and documented. When the employee incurs an exposure incident, it shall be reported to (list who has responsibility for investigation of exposure incidents): .
Following a report of an exposure incident, the exposed employee shall immediately receive a confidential medical evaluation and follow-up, including at least the following elements:
a) Documentation of the route of exposure and the circumstances under which the exposure incident occurred;
b) Identification and documentation of the source individual, unless it can be established that identification is unfeasible or prohibited by state or local law. (Employers may need to modify this provision in accordance with applicable local laws on this subject. Modifications should be listed here:
c) The source individual’s blood shall be tested as soon as feasible and after consent is obtained in order to determine HBV and HIV infectivity. If consent is not obtained, the (insert name of position/person) shall establish that legally required consent cannot be obtained. When the source individual’s consent is not required by law, the source individual’s blood, if available, shall be tested and the results documented.
d) When the source individual is already known to be infected with HBV or HIV, testing for the source individual’s known HBV or HIV status need not be repeated.
e) Results of the source individual’s testing shall be made available to the exposed employee, and the employee shall be informed of applicable laws and regulations concerning disclosure of the identity and infectious status of the source individual.
Collection and testing of blood for HBV and HIV serological status will comply with the following:
a) The exposed employee’s blood sample shall be collected as soon as feasible and tested after consent is obtained;
b) The employee will be offered the option of having his or her blood collected for testing of the employee’s HIV/HBV serological status. The blood sample will be preserved for up to 90 days to allow the employee to decide if the blood should be tested for HIV serological status.
All employees who incur an exposure incident will be offered post-exposure evaluation and follow-up in accordance with the OSHA standard. All post-exposure follow-up will be performed by (insert name of clinic, physician, department)
Information Provided To the Healthcare Professional
The (insert name of position/person) shall obtain and provide the employee with a copy of the evaluating healthcare professional’s written opinion within 15 days of the completion of the evaluation.
The healthcare professional’s written opinion for HBV vaccination shall be limited to whether HBV vaccination is indicated for an employee, and if the employee has received such vaccination.
The healthcare professional’s written opinion for post-exposure follow-up shall be limited to the following information:
a) A statement that the employee has been informed of the results of the evaluation; and
b) A statement 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.
NOTE: All other findings or diagnoses shall remain confidential and shall not be included in the written report.
12. Labels and Signs
(insert name of position/person) shall ensure that biohazard labels shall be affixed to containers of regulated waste, refrigerators and freezers containing blood or other potentially infectious materials, and other containers used to store, transport or ship blood or other potentially infectious materials.
The universal biohazard symbol shall be used. The label shall be fluorescent orange or orange-red.
Red bags or containers may be substituted for labels. However, regulated wastes must be handled in accordance with the rules and regulations of the organization having jurisdiction.
Blood products that have been released for transfusion or other clinical use are exempted from these labeling requirements.
13. Information and Training
(insert name of position/person) shall ensure that training is provided at the time of initial assignment to tasks where occupational exposure may occur, and that it shall be repeated within twelve months of the previous training. Training shall be tailored to the education and language level of the employee, and offered during the normal work shift. The training will be interactive and cover the following:
a) A copy of the standard and an explanation of its contents;
b) A discussion of the epidemiology and symptoms of bloodborne diseases;
c) An explanation of the modes of transmission of bloodborne pathogens;
d) An explanation of the (insert project name) Bloodborne Pathogen Exposure Control Plan (this program), and a method for obtaining a copy.
e) The recognition of tasks that may involve exposure.
f) An explanation of the use and limitations of methods to reduce exposure, for example engineering controls, work practices and personal protective equipment (PPE).
g) Information on the types, use, location, removal, handing, decontamination, and disposal of PPEs.
h) An explanation of the basis of selection of PPEs.
i) Information on the Hepatitis B vaccination, including efficacy, safety, method of administration, benefits, and that it will be offered free of charge.
j) Information on the appropriate actions to take and persons to contact in an emergency involving blood or other potentially infectious materials.
k) An explanation of the procedure to follow if an exposure incident occurs, including the method of reporting and medical follow-up.
l) Information on the evaluation and follow-up required after an employee exposure incident.
m) An explanation of the signs, labels and color coding systems.
The person conducting the training shall be knowledgeable in the subject matter.
Employees who have received training on bloodborne pathogens in the twelve months preceding the effective date of this policy shall only receive training in provisions of the policy that are not covered.
Additional training shall be provided to employees when there are any changes of tasks or procedures affecting the employee’s occupational exposure.
(insert name of position/person) is responsible for maintaining medical records as indicated below. These records will be kept (insert location) . (If you contract for post-exposure follow-up and Hepatitis B vaccination evaluation, make sure that your contract language includes provisions for recordkeeping, which are consistent with the requirements of 1910.20.)
Medical records shall be maintained in accordance with OSHA Standard 29 CFR 1910.20. These records shall be kept confidential and must be maintained for at least the duration of employment plus 30 years. The records shall include the following:
(insert name of position/person) is responsible for maintaining the following training records. These records will be kept (insert location) .
Training records shall be maintained for three years from the date of training. The following information shall be documented:
a) The dates of the training sessions;
b) An outline describing the material presented;
c) The names and qualifications of persons conducting the training;
d) The names and job titles of all persons attending the training sessions.
All employee records shall be made available to the employee in accordance with 29 CFR 1910.20.
All employee records shall be made available to the Assistant Secretary of Labor for the Occupational Safety and Health Administration and the Director of the National Institute for Occupational Safety and Health upon request.
PERSONAL PROTECTIVE EQUIPMENT
Both OSHA and HIOSH periodically update and revise standards. You would review both the Federal OSHA and State HIOSH websites for periodic updates.
e1910.132 GENERAL REQUIREMENTS
Hazard assessment and equipment section. The employer should assess the workplace to determine if hazards are present, or are likely to be present, which necessitate the use of personal protective equipment.
If such hazards exist, the employer should select and have each employee use, the types of PPE that will protect the affected employee from the hazards identified in the hazard assessment.
The employer should verify that the required workplace hazard assessment has been performed through a written certification that identifies the workplace evaluated; the person certifying that that evaluation has been performed; the date(s) of the hazard assessment.
The employer should provide training to each employee who is required to use PPE. Each such employee should be trained to know at least the following:
* When PPE is necessary;
* What PPE is necessary;
* How to properly don, doff, adjust, and wear PPE;
* The limitations of the PPE; and
The proper care and maintenance, useful life and disposal of the PPE.
Each affected employee should demonstrate the ability to use PPE properly, before being allowed to perform work requiring the use of PPE.
Retraining is required to include but not limited to situations where:
* Changes in the workplace render previous training obsolete, or there are changes in the types of PPE to be used or,
* If an employee demonstrates an inadequate knowledge or use of assigned personal protective equipment.
The employer should verify that each affected employee has received and understood the required training through a written certification that contains the name of each employee trained, the date(s) of training, and that identifies the subject of the certification.
e1910.133 EYE AND FACE PROTECTION
General requirements. Each affected employee should use appropriate eye or face protection when exposed to eye or face hazards from flying particles, molten metal, liquid chemicals, acids or caustic liquids, chemical gases or vapors, or potentially injurious light radiation.
Each affected employee should use eye protection that provides side protection when there is a hazard from flying objects. Detachable side protectors (e.g. clip-on or slid-on side shields) are acceptable.
Each affected employee who wears prescription lenses while engaged in operations that involve eye hazards should wear eye protection that incorporates the prescription in its design, or should wear eye protection that can be worn over the proper position of the prescription lenses.
Each affected employee should use equipment with filter lenses that have a shade appropriate for the work being performed for protection from injurious light radiation.
e1910.135 HEAD PROTECTION
General requirements. Each affected employee should wear protective helmets when working in areas where there is a potential for injury to the head from falling objects.
Protective helmets designed to reduce electrical shock hazards should be worn by each affected employee when near exposed electrical conductors which could contact the head.
e1910.136 FOOT PROTECTION
General requirements. Each affected employee should wear protective footwear when working in areas where there is a danger of foot injuries due to falling and rolling objects, or objects piercing the sole, and where such employee’s feet are exposed to electrical hazards.
e1910.138 HAND PROTECTION
General requirements. Employers should select and require employees to use appropriate hand protection when employees’ hands are exposed to hazards such as those from skin absorption of harmful substances; severe cuts or lacerations; severe abrasions; punctures; chemical burns; thermal burns; and harmful temperature extremes.
Selection. Employers should base the selection of the appropriate hand protection on an evaluation of the performance characteristics of the hand protection relative to the task(s) to be performed, conditions present, duration of use, and the hazards and potential hazards identified.
Personal protective equipment devices alone should not be relied on to provide protection against hazards, but should be used in conjunction with guards, engineering controls, and sound manufacturing controls.
If you have any questions regarding OSHA’s Personal Protective Equipment Standard, the completion of the required hazard assessment, or the selection of the proper type of personal protective equipment, please contact a Safety & Health Consultant at the nearest Industrial Indemnity office.
POST-OFFER JOB RELATED PHYSICAL EXAMINATION
Physical Examinations are conducted to ensure compliance with a regulatory standard (e.g., D.O.T./C.D.L.) or for job safety (e.g., High Altitude, SCUBA) requirements. Any RCUH position requiring a post-offer physical examination must follow these steps:
1. Job description must identify the requirement to perform a Post-Offer Physical Examination in the Physical and/or Medical Demands section of the job’s Minimum Qualifications.
2. Physical Examinations must be based on either: (a) Regulatory Specifications/Standards or (b) Job/Physical Analysis and Job Description.
3. All Physical Examinations must include an appropriate Employee Consent to Release Information form.
4. All Post-Offer Physical Examinations should be reviewed by the RCUH Human Resources Department, PRIOR to performing a physical exam. This process will allow RCUH to examine your Project’s need and rationale for conducting the physical examination. This review will also ensure the examination process within acceptable standards.
5. All other physical examinations are prohibited.
6. Results of all physical examinations are considered CONFIDENTIAL and will be stored in a locked file cabinet, and separated from all personnel records.
7. Cost of physical examination will be borne by the Project.