The Disease
 
Hepatitis B is a viral infection caused by the Hepatitis B virus (HBV) which causes death in 1-2% of those infected.  Most people with HBV recover completely, but approximately 5-10% become chronic carriers of the virus.  Most of these people have no symptoms, but can continue to transmit the disease to others.  Some may develop chronic active hepatitis and cirrhosis.  HBV may be a causative factor in the development of liver cancer.  Immunization against HBV can prevent acute hepatitis and its complications.
 
The Vaccine
 
The HBV vaccine is produced from yeast cells.  It has been extensively tested for safety and effectiveness in large scale clinical trials.
 
Approximately 90 percent of healthy people who receive two doses of the vaccine and a third dose as a booster achieve high levels of surface antibody (anti-HBs) and protection against the virus.  The HBV vaccine is recommended for workers with potential for contact with blood or body fluids.  Full immunization requires three doses of the vaccine over a six-month period, although some persons may not develop immunity even after three doses.
 
There is no evidence that the vaccine has ever caused Hepatitis B.  However, persons who have been infected with HBV prior to receiving the vaccine may go on to develop clinical hepatitis in spite of immunization.
 
Dosage and Administration
 
The vaccine is given in three intramuscular doses in the deltoid muscle.  Two initial doses are given one month apart and the third dose is given six months after the first.
 
Possible Vaccine Side Effects
 
The incidence of side effects is very low.  No serious side effects have been reported with the vaccine.  Ten to 20 percent of persons experience tenderness and redness at the site of injection and low grade fever.  Rash, nausea, joint pain, and mild fatigue have also been reported.  The possibility exists that other side effects may be identified with more extensive use.
 
 
 
CONSENT OF HEPATITIS B VACCINATION
 
I have knowledge of Hepatitis B and the Hepatitis B vaccination.  I have had an opportunity to ask questions of a qualified nurse or physician and understand the benefits and risks of Hepatitis B vaccination.  I understand that I must have three doses of the vaccine to obtain immunity.  However, as with all medical treatment, there is no guarantee that I will become immune or that I will not experience side effects from the vaccine.  I give my consent to be vaccinated for Hepatitis B.
 
 
___________________________________                          ______________________
Signature of Employee(consent for Hepatitis B vaccination)                        Date
 
___________________________________                          ______________________
Signature of Witness                                                                                     Date
 
 
 
REFUSAL OF HEPATITIS B VACCINATION
 
 
I understand that due to my occupational exposure to blood or other potentially infectious materials I may be at risk of acquiring the Hepatitis B virus infection.  I have been given the opportunity to be vaccinated with Hepatitis B vaccine at no charge to myself.  However, I decline the 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 the Hepatitis B vaccine, I can receive the vaccination series at no charge to me.
 
___________________________________                          ______________________
Signature of Employee(refusal for Hepatitis B vaccination)                         Date
 
___________________________________                          ______________________
Signature of Witness                                                                                     Date
 
 
I refuse because I believe I have (check one)
 
          started the series           completed the series
 
 
 
 
RELEASE FOR HEPATITIS B MEDICAL INFORMATION
 
I hereby authorize                                           (individual or organization holding Hepatitis B records and address) to release to the                               
Community School District, my Hepatitis B vaccination records for required employee records.
 
I hereby authorize release of my Hepatitis B status to a health care provider, in the event of an exposure incident.
 
 
___________________________________                                      ______________________
Signature of Employee                                                                        Date
 
___________________________________                                      ______________________
Signature of Witness                                                                            Date
 
 
 
CONFIDENTIAL RECORD
 
 
___________________________________________                      ______________________
               Employee Name (Last, First, Middle)                                       Social Security Number
 
Job Title: _____________________________________________________________________
 
Hepatitis B Vaccination Date            Lot Number                    Site                  Administered By
 
1._______________________          ________________    ___________    __________________
2._______________________          ________________    ___________    __________________
3._______________________          ________________    ___________    __________________
 
 
Additional Hepatitis B Status Information
__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
 
Post-exposure Incident (Date, Time, Circumstances, route under which exposure occurred)
__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
 
Identification and documentation of source individual:
______________________________________________________________________________
 
Source blood testing consent:
______________________________________________________________________________
 
Description of employee’s duties as related to the exposure incident:
__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
 
Copy of information provided to health care professional evaluating an employee after exposure incident:
__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
 
Attach a copy of all result of examinations, medical testing, follow-up procedures, and health-care professional’s written opinion.
 
Training Record: (date, time, instructor, location of training summary)
__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Take a look at the changes.

_Marked as resolved_

_Re-opened_
 
UPLOAD FORM

Universal precautions (UP) are intended to prevent transmission of infection, as well as decrease the risk of exposure for employees and students.  It is not currently possible to identify all infected individuals, thus precautions must be used with every individual.  UP pertain to blood and other potentially infectious materials (OPIM) containing blood.  These precautions do not apply to other body fluids and wastes (OBFW) such as saliva, sputum, feces, tears, nasal secretions, vomitus and urine unless blood is visible in the material.  However, these OBFW can be sources of other infections and should be handled as if they are infectious.  The single most important step in preventing exposure to and transmission of any infection is anticipating potential contact with infectious materials in routine as well as emergency situations.  Based on the type of possible contact, employees and students should be prepared to use the appropriate precautions prior to the contact.  Diligent and proper hand washing, the use of barriers, appropriate disposal of waste products and needles, and proper decontamination of spills are essential techniques of infection control.  All individuals should respond to situations practicing UP followed by the activation of the school response team plan.  Using common sense in the application of these measures will enhance protection of employees and students.
 
Hand Washing
 
Proper hand washing is crucial to preventing the spread of infection.  Textured jewelry on the hands or wrists should be removed prior to washing and kept off until completion of the procedure and the hands are rewashed.  Use of running water, lathering with soap and using friction to clean all hand surfaces is key.  Rinse well with running water and dry hands with paper towels.
 
        Hands should be washed before physical contact with individuals and after contact is completed.
        Hands should be washed after contact with any used equipment.
        If hands (or other skin) come into contact with blood or body fluids, hands should be washed immediately before touching anything else.
        Hands should be washed whether gloves are worn or not and, if gloves are worn, after the gloves are removed.
 
Barriers
 
Barriers anticipated to be used at school include disposable gloves, absorbent materials and resuscitation devices.  Their use is intended to reduce the risk of contact with blood and body fluids as well as to control the spread of infectious agents from individual to individual.  Gloves should be worn when in contact with blood, OPIM or OBFW.  Gloves should be removed without touching the outside and disposed of after each use.
 
 
Disposal of Waste
 
Blood, OPIM, OBFW, used gloves, barriers and absorbent materials should be placed in a plastic bag and disposed of in the usual procedure.  When the blood or OPIM is liquid, semi-liquid or caked with dried blood, it is not absorbed in materials, and is capable of releasing the substance if compressed, special disposal as regulated waste is required.  A band-aid, towel, sanitary napkin or other absorbed waste that does not have the potential of releasing the waste if compressed would not be considered regulated waste.  It is anticipated schools would only have regulated waste in the case of a severe incident.  Needles, syringes and other sharp disposable objects should be placed in special puncture-proof containers and disposed of as regulated waste.  Bodily wastes such as urine, vomitus or feces should be disposed of in the sanitary sewer system.
 
Clean up
 
Spills of blood and OPIM should be cleaned up immediately.  The employee should:
 
                        Wear gloves.
                        Clean up the spill with paper towels or other absorbent material.
                        Use a solution of one part household bleach to one hundred parts of water (1:100) or other EPA-approved disinfectant and use it to wash the area well.
                        Dispose of gloves, soiled towels and other waste in a plastic bag.
                        Clean and disinfect reusable supplies and equipment.
 
Laundry
 
Laundry with blood or OPIM should be handled as little as possible with a minimum of agitation.  It should be bagged at the location.  If it has the potential of releasing the substance when compacted, regulated waste guidelines should be followed.  Employees who have contact with this laundry should wear protective barriers.
 
Exposure
 
An exposure to blood or OPIM through contact with broken skin, mucous membrane or by needle or sharp stick requires immediate washing, reporting and follow-up.
 
                        Always wash the exposed area immediately with soap and water.
                        If a mucous membrane splash (eye or mouth) or exposure of broken skin occurs, irrigate or wash the area thoroughly.
                        If a cut or needle stick injury occurs, wash the area thoroughly with soap and water.
 
The exposure should be reported immediately, the parent or guardian is notified, and the person exposed contacts a physician for further health care.
 
 

EMPLOYEES ARE HEREBY NOTIFIED it is a violation of the Substance-Free Workplace policy for an employee to unlawfully manufacture, distribute, dispense, possess, use, or be under the influence of in the workplace any narcotic drug, hallucinogenic drug, amphetamine, barbiturate, marijuana or any other controlled substance or alcohol, as defined in Schedules I through V of section 202 of the Controlled Substances Act (21 U.S.C. 812) and as further defined by regulation at 21 C.F.R. 1300.11 through 1300.15 and Iowa Code Chapter 124.
 
"Workplace" is defined as the site for the performance of work done in the capacity as an employee.  This includes school district facilities, other school premises or school district vehicles.  Workplace also includes nonschool property if the employee is at any school-sponsored, school-approved or school-related activity, event or function, such as field trips or athletic events where students are under the control of the school district or where the employee is engaged in school business.
 
[Employees who violate the terms of the Substance-Free Workplace policy may be required to successfully participate in a substance abuse treatment program approved by the board.]  The superintendent retains the discretion to discipline an employee for violation of the Substance-Free Workplace policy.  If the employee fails to successfully participate in such a program the employee is subject to discipline up to and including termination.
 
EMPLOYEES ARE FURTHER NOTIFIED it is a condition of their continued employment that they comply with the above policy of the school district and will notify their supervisor of their conviction of any criminal drug statute for a violation committed in the workplace, no later than five days after the conviction.
 
 
---------------------------------------------------------------------------------------
 
SUBSTANCE-FREE WORKPLACE ACKNOWLEDGMENT FORM
 
I,                                                    , have read and understand the Substance-Free Workplace policy.  I understand that if I violate the Substance-Free Workplace policy, I may be subject to discipline up to and including termination [or I may be required to participate in a substance abuse treatment program].  If I fail to successfully participate in a substance abuse treatment program, I understand I may be subject to discipline up to and including termination.  I understand that if I am required to participate in a substance abuse treatment program and I refuse to participate, I may be subject to discipline up to and including termination.  I also understand that if I am convicted of a criminal drug offense committed in the workplace, I must report that conviction to my supervisor within five days of the conviction.
 
 
 

(Signature of Employee)

(Date)

A superintendent who suspects an employee has a substance abuse problem will follow these procedures:

1. Identification - the superintendent will document the evidence the superintendent has which leads the superintendent to conclude the employee has violated the Substance-Free Workplace policy.  After the superintendent has determined there has been a violation of the Substance-Free Workplace policy, the superintendent will discuss the problem with the employee.
2. Discipline - if, after the discussion with the employee, the superintendent determines there has been a violation of the Substance-Free Workplace policy, the superintendent may recommend discipline up to and including termination or may recommend the employee seek substance abuse treatment.  Participation in a substance abuse treatment program is voluntary.
3. Failure to participate in referral – if the employee refuses to participate in a substance abuse treatment program or if the employee does not successfully complete a substance abuse treatment program, the employee may be subject to discipline up to and including termination.
4. Conviction - if an employee is convicted of a criminal drug offense committed in the workplace, the employee must notify the employer of the conviction within five days of the conviction.

EMPLOYEES GOVERNED BY THE DRUG AND ALCOHOL TESTING POLICY ARE HEREBY NOTIFIED they are subject to the school district's drug and alcohol testing program for pre-employment drug testing and random, reasonable suspicion, post-accident drug and alcohol testing as outlined in the Drug and Alcohol Testing Program policy, its supporting documents and the law.
 
Employees who operate school vehicles are subject to drug and alcohol testing if a commercial driver's license is required to operate the school vehicle and the school vehicle transports sixteen or more persons including the driver or the school vehicle weighs twenty-six thousand, one pounds or more.  For purposes of the drug and alcohol testing program, "employees" also includes applicants who have been offered a position to operate a school vehicle.  The employees operating a school vehicle are subject to the drug and alcohol testing program beginning the first day they operate or are offered a position to operate a school vehicle and continue to be subject to the drug and alcohol testing program.
 
It is the responsibility of the superintendent to inform employees of the drug and alcohol testing program requirements.  Employees with questions regarding the drug and alcohol testing requirements will contact the school district contact person.
 
EMPLOYEES GOVERNED BY THE DRUG AND ALCOHOL TESTING POLICY ARE FURTHER NOTIFIED that employees violating this policy, its supporting documents or the law may be subject to discipline up to and including termination.
 
EMPLOYEES GOVERNED BY THE DRUG AND ALCOHOL TESTING POLICY ARE FURTHER NOTIFIED it is a condition of their continued employment to comply with the Drug and Alcohol Testing Program policy, its supporting documents and the law.  It is a condition of continued employment for employees operating a school vehicle to notify their supervisor of any prescription medication they are using.  Drug and alcohol testing records about a driver are confidential and are released in accordance with this policy, its supporting documents or the law.
 
EMPLOYEES GOVERNED BY THE DRUG AND ALCOHOL TESTING POLICY ARE FURTHER NOTIFIED that employees violating this policy, its supporting documents or the law may be subject to discipline up to and including termination.  As a condition of employment, employees violating this policy, its supporting documents or the law bear the personal and financial responsibility, as a condition of continued employment, to successfully participate in a substance abuse evaluation and, a substance abuse treatment program recommended by the substance abuse professional.  Employees required to participate in and who fail to or refuse to successfully participate in a substance abuse evaluation or recommended substance abuse treatment program may be subject to discipline up to and including termination.

I,  ______________________________ have received a copy, read and understand the Drug and Alcohol Testing Program policy of the Winfield – Mt. Union  School District and its supporting documents. 
                                     
I understand that if I violate the Drug and Alcohol Testing Program policy, its supporting documents or the law, I may be subject to discipline up to and including termination.
 
I also understand that I must inform my supervisor of any prescription medication I use. 
 
In addition, I have received a copy of the U.S. DOT publication, “What Employees Need to Know about DOT Drug & Alcohol Testing,” and have read and understand its contents.
 
Furthermore, I know and understand that I am required to submit to a controlled substance (drug) test, the results of which must be received by this employer before being employed by the school district and before being allowed to perform a safety-sensitive function.  I also understand that if the results of the pre-employment test are positive, that I will not be considered further for employment with the school district.
 
I further understand that drug and alcohol testing records and information about me are confidential, and may be released at my request or in accordance with the district’s drug and alcohol testing program policy, its supporting documents or the law.
 
_____________________________               ________________________
(Signature of Employee)                                                                            (Date)