8/10/2019 Bloodborne at Risk Assessment

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BLOODBORNE PATHOGEN AT RISK ASSESSMENT

Department: Employee ID:

Employee Name: University ID #:

Job Code: Appointment Date:

The above employee is not at is! "o e#pos$e to bloo% o OPIM& (skip to Part III)'

Completion of tis form provides do!"mentation spe!ifyin te $ob tasks or pro!ed"res tat pla!e an employee at risk of e%pos"re& as re'"in *A+s ,loodborne Patoens tandard (-. C/0 1.1231242)3 5e $ob d"ties listed belo6 !reate a potential for o!!"pational e%pos"rblood or oter potentially infe!tio"s material (PI78)3 Please !e!k ea! bo% tat refle!ts $ob d"ties for te above named employee and tis do!"ment 6it yo"r department+s E%pos"re Control Plan3

Ma!e% bo#es in%i(ate tas!)s* pe"ome%+

13 9orks 6it "man blood or blood prod"!ts (e33& ser"m& platelets& !ells)3

-3 *andles !ontainers oldin "man blood or blood prod"!ts3

43 9orks 6it "man !ell lines3

3 9orks 6it *epatitis , vir"s (*,;) or preparations tat !ontain *,;3

"man primates infe!ted 6it *,; or !leans areas 6ere tis 6ork is performed3

?3 *andles blood& blood prod"!ts& body fl"ids& or "nfi%ed tiss"es from animals infe!ted 6it te *,;3

@3 *andles "nfi%ed fres or froen "man tiss"es or orans3 (/i%ed refers to preservation in sol"tions s"! as formaldeyde or al!ool3)

.3 *andles sarp instr"ments "sed for any of te 6ork listed on tis form3

123 9orks in patient !are 6it potential for !onta!t 6it blood or PI783

113 9orks in a dental settin 6it e%pos"re to "man blood& saliva& oral tiss"es& or e%tra!ted teet3

1-3 Colle!ts or disposes of bioaard 6aste or sarps !ontainers3

143 ter (spe!ify):

Depatmental Responsibility+

(5e employee m$stre!eive te follo6in):

13 Initial and ann"al refreser bloodborne patoens trainin3 Call Environmental *ealt B afety at @4=4-3 9aiver forms are available tro" E*s 6ebsor UE*C (send !ompleted forms to: UE*C& 12.?>1 ,oyd 5o6er)3

"pervisor+s inat"re: Date:

),ile -ith the Depatment.s E#pos$e /ontol Plan*

8-. C/0 1.12312423 b3 Definitions: ter Potentially Infe!tio"s 7aterials (PI7) are defined as: (1) te follo6in "man body fl"ids: semevainal se!retions& !erebrospinal fl"id& synovial fl"id& ple"ral fl"id& peri!ardial fl"id& peritoneal fl"id& amnioti! fl"id& saliva in dental pro!ed"reany body fl"id tat is visibly !ontaminated 6it blood& and all body fl"ids in sit"ations 6ere it is diffi!"lt or impossible to differentiate bet6eebody fl"ids (-) any "nfi%ed tiss"e or oran (oter tan inta!t skin) from a "man (livin or dead) and (4) *I;>!ontainin !ell or tiss"e !"lt"roran !"lt"res& and *I;>or *,;>!ontainin !"lt"re medi"m or oter sol"tions& and blood& orans& or oter tiss"es from e%perimental animalnfe!ted 6it *I; or *,;3

Updated !t3 -