UW Madison Occupational Health Surveillance Procedures by wuzhenguang

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									                                           Title: UW Madison Occupational Health Surveillance Procedures
                                                                      Document Number: OH-GUI-035
                                                                                         Revision: NEW
                                                                             Date Approved: 04/17/2012


           UW Madison Occupational Health Surveillance Procedures

1.0 Introduction
The University of Wisconsin-Madison’s Occupational Health Program and University Health
Services (UHS) manage the Occupational Health Surveillance Program for the University of
Wisconsin-Madison. UHS provides health assessments for staff and students; oversees the
campus immunization program; and coordinates the provision of medical assessment and
treatment for exposures related to the research enterprise. Refer to Appendix A for eligibility for
UHS services.

Pre-exposure and periodic health assessments are a critical component of the Occupational
Health Surveillance Program. Health assessments vary in content in relation to the job task or
exposure that they are designed to evaluate as well as the health status of the employee. Certain
job descriptions/position categories require multiple assessments in the form of history and
physical examination, laboratory studies, and/or other diagnostic testing.

2.0 Related Documents
       2.1 UW Madison Occupational Health Surveillance Policy
       2.2 UW Madison Serum Banking and Testing Guidance
       2.3 Template for Disclosure of Workplace Hazards and Risks
       2.4 Declination Form Template (Appendix D)
       2.5 Informed Consent Template (Appendix E)

3.0 Health Assessments
Two basic types of assessments are used to monitor occupational health.

       3.1 Questionnaire-based surveillance. Questionnaires review an individual’s health
           history and job related risks. Review of the questionnaire may generate requirements
           for testing, immunization, training, personal protective equipment, and/or
           requirements for periodic surveillance. In some cases, a more in-depth assessment
           with an occupational medicine provider may be required.

       3.2 Occupational Medicine Visit. Some job risks or exposures require an actual on-site
           health assessment, which will include a history and physical exam, and may
           additionally, include laboratory testing, diagnostic testing, and/or review/update of
           immunizations.

4.0 Information Management
Records of employee participation in occupational health surveillance activities should be kept in
the employing department within an employee health record. This employee-specific file must be
separate from personnel files and should include written statements about an employee’s fitness
for duty as required by the Occupational Safety and Health Administration (OSHA), vaccination
records or declination statements, exposure monitoring data and assignment of personal
protective equipment. The employee health record should not include medical diagnosis


                                          6/2/11                                              1
                                           Title: UW Madison Occupational Health Surveillance Procedures
                                                                      Document Number: OH-GUI-035
                                                                                         Revision: NEW
                                                                             Date Approved: 04/17/2012

statements or test results. Such information is part of the patient health record. Information in the
patient health record is protected under the Health Insurance Portability and Accountability Act
(HIPAA) and must remain with the treating medical provider. Copies of employee health record
information should also be forwarded to the Occupational Health Program. Once an employee
leaves employment, the employing department should send the employee participation records to
the Occupational Health Program. OSHA requires employee health records to be kept for 30
years after the termination date. UHS will manage patient records.

5.0 Health Surveillance Procedures

       5.1 Definition and Assignment of Job Risk Categories: The Occupational Health
           Officer will develop job specific risk categories in consultation with University
           Health Services and campus employers. Job specific risk categories are included in
           Section 9.0. Job risk categories are generally associated with specific pre-exposure
           health assessment, training, personal protective equipment, and/or prophylaxis
           recommendations. In some cases, additional periodic assessments are
           recommended/required. Any given employee and/or position may fall into one or
           several job risk categories.

       5.2 Exposure Determinations: In many cases, the offer of health services is dependent
           on the level of workplace exposure to a particular agent or hazard. Examples include
           noise, asbestos, and lead. For assistance in determining workplace exposure levels,
           contact the Occupational Health Program at 265-5000.

       5.3 Assignment of Job Risk Categories to Position Descriptions: The Occupational
           Health Officer or his/her designee will assist departments in determining the
           appropriate job risk categories for their employees. When possible, these job risk
           categories and health surveillance recommendations will be included in the employee
           position description.

       5.4 Initiation of Surveillance Services: The supervisor and/or department is responsible
           for ensuring that all employees are offered recommended/required health assessment
           services before employment begins or exposure occurs. Service requests are initiated
           by calling 265-5610. The patient will be given an appointment and instructed to fill
           out a requisition form and to include an appropriate funding string. If there is interest
           in delivering services on-site, such as with respirator fit testing, vaccinations or Tb
           screening, the occupational health nurse should be contacted at 265-5610 to discuss
           arrangements.

       5.5 Subsequent Surveillance Services: UHS and the campus Occupational Health
           Officer will be responsible for tracking employees and students who require periodic
           health assessments based on their job risk category and/or personal health status.
           Employees and students will receive notification when services are due. In the event
           an employee/student does not respond, supervisors will be notified and be responsible
           for subsequent follow-up.


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                                           Title: UW Madison Occupational Health Surveillance Procedures
                                                                      Document Number: OH-GUI-035
                                                                                         Revision: NEW
                                                                             Date Approved: 04/17/2012




6.0 Disclosure of Hazards
The campus Hazard Communication and Chemical Hygiene Programs address communication of
hazards typically found in the workplace. Additional disclosure is helpful where agents requiring
significant containment or that are particularly hazardous are used. Such disclosure can help the
supervisor assure necessary information was shared and understood. Where available, a material
safety data sheet (MSDS) can be used to facilitate this discussion. A form such as that in
Appendix B can be used to document communication.

7.0 Serum Banking
In some cases, serum collection and testing may be a useful tool in monitoring workplace safety.
However, serum banking should only be done where there is defined purpose in doing so. There
are many complicating factors such as interpretation of results, reliability of long term sample
storage and utility of data for diagnostic purposes. The collection of baseline serum for
individuals exposed to infectious agents will be determined on a case by case basis. Participation
shall be voluntary. If individuals do not participate, they should sign a declination statement.
Serum samples will be used for diagnostic purposes only. Principle investigators (PIs) should
consult with University Health Services, Institutional Biosafety Committee and Occupational
Health Program in determining whether serum banking should be implemented. When deemed
necessary, individuals should make an appointment with UHS for a baseline serum draw. The
serum sample will be shipped to a secure off-site serum storage facility. Samples will not be
removed for testing without consent of the patient. Employing departments will be responsible
for the cost of sample collection and storage. Refer to Appendix C for guidance on serum
banking.

8.0 Payment for Occupational Health Surveillance Services

       8.1 Pre-Exposure: With the exception of the Animal Handling Risk Questionnaire
           review, the costs for all pre-exposure medical surveillance services are the
           responsibility of the employing department or student. A link to the UHS fee schedule
           is included in Appendix F.

       8.2 Post-Exposure Costs: When employees seek medical services related to a workplace
           exposure, the relationship of the medical service visit to workplace activity should be
           stated clearly. Billing should be directed to UW Madison Workers Compensation, 21
           N. Park Street, Madison, WI 53715.

       8.3 Student-Related Costs: Pre-exposure services may be covered by a student’s private
           health insurance when outside the scope of the student activity fee. Where costs are
           not covered, departments are encouraged to cover them or develop policies related to
           student responsibility. A list of services covered by the student activity fee is included
           in Appendix G.



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                                          Title: UW Madison Occupational Health Surveillance Procedures
                                                                     Document Number: OH-GUI-035
                                                                                        Revision: NEW
                                                                            Date Approved: 04/17/2012



9.0 Job Duties or Exposures that Trigger a Health Assessment and Associated Health
    Assessment Components

       9.1 Animal Contact- General

Definition: Individuals who have direct exposure to vertebrate animals, animal tissues, body
fluids or wastes.
Health Assessment: Completion of Animal Contact Risk Questionnaire (and medical exam if
deemed appropriate by medical reviewer) every 3 years, when change in health status or
otherwise indicated by medical reviewer
Forms: Animal Contact Risk Questionnaire
Labs: Serum for banking – as determined by physician
Immunizations: Tetanus Immunization within 10 years
Other: Respirator clearance and annual fit testing– All individuals requiring respirator use to
perform their job duties

       9.2 Animal Contact- Carnivores

Definition: Individuals in contact with unvaccinated carnivores or other species known to be
carriers of rabies
Health Assessment: Completion of Animal Contact Risk Questionnaire (and medical exam if
deemed appropriate by medical reviewer) every 3 years, when change in health status or
otherwise indicated by medical reviewer
Forms: Animal Handling Risk Questionnaire
Immunizations: Tetanus Immunization within 10 years, Rabies immunization- completion of
rabies series or positive (+) titer within 2 years

       9.3 Animal Contact- Non-Human Primates

Definition: Individuals who have direct exposure to non-human primates, their tissues, body
fluids or wastes.
Health Assessment: Completion of Animal Contact Risk Questionnaire (and medical exam if
deemed appropriate by medical reviewer) every 3 years, when change in health status or
otherwise indicated by medical reviewer.
Forms: Animal Handling Risk Questionnaire
Labs: Tuberculosis Screening (PPD) every 6 months (or Quantiferon Gold and/or symptom
screen with annual exam )- All individuals in contact with non-human primates
Immunizations: Tetanus immunization every 10 years
Other: Respirator clearance at intervals determined by medical reviewer and fit testing every
year




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                                          Title: UW Madison Occupational Health Surveillance Procedures
                                                                     Document Number: OH-GUI-035
                                                                                        Revision: NEW
                                                                            Date Approved: 04/17/2012



       9.4 Asbestos Abatement

Definition: Individuals involved in an abatement effort, such as entering containment,
performing glove bag removals, or operations and maintenance related asbestos removal as
defined in 29CFR1910.1001.
Health Assessment: Annual medical exam and review of immunizations. Must also participate
in the Respiratory Protection Program (see Respirator Use below).
Forms: Physical exam, Medical History , Medical Questionnaire for Respirator Use, Fitness for
Duty statement will be completed by Physician and sent to employee and supervisor.
Immunizations: Tetanus immunization every 10 years
Other: Baseline chest x-ray with B reader interpretation according to OSHA required frequency,
baseline and annual pulmonary function test


       9.5 Bloodborne Pathogen Contact

Definition: Routine work with blood, blood products or other human infectious materials as
defined in 29CFR1910.1030.
Forms: Hepatitis B Vaccination Statement or Declination Form
Immunizations: Series of three Hepatitis B vaccinations
Other: Employees/students who have routine exposure will be offered Hepatitis B vaccination
and will be strongly counseled to accept. If an employee/student declines, they will be required
to sign a declination statement. Post vaccination testing should be done 1-2 months after the last
dose of Hepatitis B vaccine for staff engaged in patient contact or diagnostic lab operations.

       9.6 Work with Select Carcinogens

Definition: Work with carcinogens identified in OSHA 29CFR1910.1003. Examples include
benzidine, bis-Chloromethyl ether and N-Nitrosodimethylamine.
Assessment: Baseline medical exam, then at intervals determined by physician
Forms: Work and health history
Labs: Physician discretion

       9.7 Chemical Exposure Incidents

Definition: Exposure to hazardous chemical release or development of symptoms consistent
with chemical exposure as defined in 29CFR1910.1450.
Assessment: Medical exam as determined by physician
Forms: Medical and health history.
Labs: Physician discretion




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                                          Title: UW Madison Occupational Health Surveillance Procedures
                                                                     Document Number: OH-GUI-035
                                                                                        Revision: NEW
                                                                            Date Approved: 04/17/2012



       9.8 Commercial Driver License

Definition: For those required to have a commercial driver license as part of their UW
employment defined in 49 CFR 391, Subpart E.
Health Assessment: Department of Transportation Physical Examination
Forms: Department of Transportation CDL exam form (available during exam), medical history
Labs: Urinalysis
Immunizations: Tetanus immunization every 10 years
Other: Physical examinations as appropriate for the duration of time that the employee is
required to operate a commercial motor vehicle, vision exam

       9.9 Formaldehyde

Definition: Work with formaldehyde resulting in exposures above 0.75 ppm over an 8 hour
period or 2 ppm over 15 minutes as defined in 29CFR1910.1048.
Assessment: Annual medical exam at intervals determined by physician
Forms: Work and health history.
Other: Annual pulmonary function testing

       9.10   Hazardous Waste

Definition: Work with hazardous waste at a treatment, storage or disposal facility or
participation in a hazardous material response team as defined in 29CFR1910.120.
Assessment: Annual medical exam
Forms: Work and health history.
Immunizations: Tetanus immunization every 10 years
Labs: CBC, kidney and liver function, urinalysis
Other: Respirator clearance and fit testing when use is required

       9.11   Laser Use

Definition: Work with class 3b or 4 lasers as defined in ANSI-Z-136.1.
Assessment: Exam with refraction, using laser screening exam form, photography- fundus pre-
assignment, post exposure and exit as indicated
Forms: Work and health history

       9.12   Lead

Definition: Work with lead-containing materials creating exposures above 30 micrograms per
cubic meter as defined in 29CFR1910.1025.
Health Assessment: Baseline medical exam, repeated at intervals determined by physician
Forms: Work and health history
Labs: As required; could include blood and Zinc protoporphyrin (ZPP) every six months,
hemoglobin and hematocrit determinations, red cell indices, and examination of peripheral smear


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                                         Title: UW Madison Occupational Health Surveillance Procedures
                                                                    Document Number: OH-GUI-035
                                                                                       Revision: NEW
                                                                           Date Approved: 04/17/2012

morphology; Blood urea nitrogen; and, Serum creatinine; routine urinalysis with microscopic
examination;.

       9.13   Noise, Work in Areas of Excessive Noise

Definition: Work in an environment with a noise level of 85db or greater as defined in
29CFR1910.95.
Assessment: Baseline and annual audiograms and enrollment in a Hearing Conservation
Program
Forms: UHS Occupational Medicine Requisition

       9.14   Nuclear Reactor Operator

Definition: Staff requiring an NRC license to operate a nuclear reactor as defined in 10CFR 55,
American Nuclear Society, ANSI/ ANS-3.4-1996.
Assessment: Medical exam every 2 years
Labs: EKG, CBC, Fasting Lipid, Comprehensive Metabolic Panel every 2 years.
Forms: NRC-396
Other: Vision screen and audiogram every 2 years

       9.15   Patient Contact

Definition: Having physical or face-to-face contact with a patient, or having contact with
potentially contaminated items including (but not limited to) blood and/or body fluids
Health Assessment: review of health history and immunization records
Forms: Medical and work history
Labs: Titers if indicated
Immunizations: Two PPD’s, within the 12 month period prior to commencement of
employment. For prior positive PPDs, a chest x-ray current within 12 months prior to UW start
date is accepted or chest Xray (CXR) from UHS is required. Persons with a history of BCG
vaccination are required to have the PPDs unless they have documentation of a previously
positive PPD. Tb surveillance of symptoms required if past positive PPD. Two doses each of
Measles, Mumps, and Rubella. Measles Mumps and Rubella titers showing evidence of
immunity can be substituted for this requirement. Documented blood titer confirming disease
immunity or proof of two doses of Varicella Vaccine. One Tetanus, diphtheria and pertussis
(Tdap) vaccination within previous 10 years. Annual influenza vaccination recommended. If a
patient contact employee/candidate does not meet PPD and immunization/titer requirements, that
individual will be listed as "Under Review” until these requirements are met.
Other: N95 medical clearance for annual respirator fit testing

       9.16   Pesticide Use

Definition: Individuals who use Class 1 & 2 organophosphate and carbamate pesticides.
Health Assessment: Medical exam every 3 years or at interval determined by physician.
Forms: Preplacement physical exam, medical history


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                                         Title: UW Madison Occupational Health Surveillance Procedures
                                                                    Document Number: OH-GUI-035
                                                                                       Revision: NEW
                                                                           Date Approved: 04/17/2012

Labs: CBC, Comprehensive Metabolic Panel, CGT, RBC Cholinesterase every 3 years.
Immunizations: Tetanus immunization every 10 years
Other: Respirator clearance including pulmonary function test (PFT), Audiogram, subsequent
exam according to frequency recommended by UHS occupational medicine with interval from 1-
3 years based on pesticide use and/or medical findings.

       9.17   Pregnancy or Reproductive Health Questions

Definition: Individuals who have questions pertaining to the impact of their work or study
activities on reproductive capacity or pregnancy.
Health Assessment: Medical exam (consult)
Forms: Work and health history

       9.18   Prophylaxis for Laboratory Work with Special Agents

Definition: Individuals who require medication to prevent illness associated with chemical or
infectious laboratory agents.
Health Assessment: Medical Exam
Forms: Work and health History
Labs: Physician discretion

       9.19   Respirator Use

Definition: For individuals required to wear a respirator on a routine or emergency basis as
defined in 29CFR1910.134. Users covered under more specific exposure groups may have
additional requirements.
Health Assessment: Respirator Use Medical Evaluation Questionnaire with review and medical
exam if indicated in baseline review
Forms: Respirator Use Medical Evaluation Questionnaire




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         Human
         Animal
         Animal
         Animal

         General

         Contact-
         Contact-




         Primates
         Asbestos


         Exposure
         Abatement
         Carnivores




         Bloodborne
         Contact- Non-
                             Assessment




                 X
                     X
                         X
                             Animal Contact Risk Questionnaire

                             Consult




                 S
                         S




             X
                             Respirator Questionnaire




                 S
                         S




             X
                             Physical exam

                             Audiometry

                             Eye exam




6/2/11
                             Immunizations
                                                                    = Item specific to a situation




         X
                             Hepatitis B




             X
                 X
                     X
                         X
                             Tetanus

                             Influenza




                         S


                     X
                             Rabies

                             MMR/Varicella

                             Labs
                                                                                                                                   Table 1




                 S
                         S


                             Serum Banking

                             Blood Lead/ZPP




9
                 X
                             Tb Screening (PPD or medical review)

                             CBC (Complete Blood Count)

                             Cholinesterase

                             Drug/Alcohol Screen

                             Kidney Function Tests BUN
                                                                                                     Job Duties/Conditions and Health Assessment Components at a Glance




                             LFTs (Liver Function Tests) AST AL

                             U/A (Urinalysis)

                             Titers
         S




                             HBV



                             Diagnostic
                 S
                         S




             X




                             PFT
                                                                                                                                                                          Title: UW Madison Occupational Health Surveillance Procedures

                                                                                                                                                                                                                        Revision: NEW
                                                                                                                                                                                                            Date Approved: 04/17/2012
                                                                                                                                                                                                     Document Number: OH-GUI-035




             X




                             Chest Xray
                            1
                                             Lead

                                             Noise
                                             Waste
                                             Drivers
                                             License




                                             Nuclear1
                                             Operator
                                             Exposure
                                             Exposure
                                             Exposure




                                             Exposure
                                             Chemical




                                             Laser Use
                                             Lab Work




                                             Hazardous
                                             Carcinogen



                                             Commercial


                                             Formaldehyde
                                                                                 Assessment

                                                                                 Animal Contact Risk Questionnaire

                                                                                 Consult




                                             X
                                                     X
                                                             X
                                                                                 Respirator Questionnaire




         Also requires lipid panel and EKG
                                             X
                                                     X
                                                             X
                                                                 X
                                                                     X
                                                                         X
                                                                             X
                                                                                 Physical exam




                                             X
                                                 X
                                                                                 Audiometry




                                             X
                                                         X
                                                                     X
                                                                                 Eye exam




6/2/11
                                                                                 Immunizations

                                                                                 Hepatitis B




                                                             X
                                                                     X
                                                                                 Tetanus

                                                                                 Influenza

                                                                                 Rabies

                                                                                 MMR/Varicella

                                                                                 Labs

                                                                                 Serum Banking


                                                     X
                                                                                 Blood Lead/ZPP




10
                                                                                 Tb Screening (PPD or medical review)
                                                     S
                                                                         S
                                                                             S




                                             X
                                                             X




                                                                                 CBC (Complete Blood Count)

                                                                                 Cholinesterase

                                                                                 Drug/Alcohol Screen
                                                     S
                                                                         S
                                                                             S




                                             X
                                                             X




                                                                                 Kidney Function Tests BUN
                                                     S
                                                                         S
                                                                             S




                                             X
                                                             X




                                                                                 LFTs (Liver Function Tests) AST AL
                                                     S
                                                                         S
                                                                             S




                                                             X
                                                                     X




                                                                                 U/A (Urinalysis)

                                                                                 Titers

                                                                                 HBV



                                                                                 Diagnostic
                                                             S
                                                                 S




                                                     X




                                                                                 PFT
                                                                                                                        Title: UW Madison Occupational Health Surveillance Procedures

                                                                                                                                                                      Revision: NEW
                                                                                                                                                          Date Approved: 04/17/2012
                                                                                                                                                   Document Number: OH-GUI-035




                                                                                 Chest Xray
         Use
         Patient
         Contact




         Respirator
         Prophylaxis
         Pesticide Use
         Special Agent
                         Assessment

                         Animal Contact Risk Questionnaire

                         Consult




         X
                 X
                         Respirator Questionnaire




         S
             X
                 X
                     X
                         Physical exam




                 X
                         Audiometry

                         Eye exam




6/2/11
                         Immunizations




                     X
                         Hepatitis B




                 X
                     X
                         Tetanus

                         Influenza

                         Rabies
                     X




                         MMR/Varicella

                         Labs

                         Serum Banking

                         Blood Lead/ZPP




11
                         Tb Screening (PPD or medical review)
                 X




                         CBC (Complete Blood Count)
                 X




                         Cholinesterase

                         Drug/Alcohol Screen
                 X




                         Kidney Function Tests BUN
                 X




                         LFTs (Liver Function Tests) AST AL

                         U/A (Urinalysis)

                         Titers

                         HBV



                         Diagnostic
         S
                 X




                         PFT
                                                                Title: UW Madison Occupational Health Surveillance Procedures

                                                                                                              Revision: NEW
                                                                                                  Date Approved: 04/17/2012
                                                                                           Document Number: OH-GUI-035




                         Chest Xray
                                 Title: UW Madison Occupational Health Surveillance Procedures
                                                            Document Number: OH-GUI-035
                                                                               Revision: NEW
                                                                   Date Approved: 04/17/2012




10.0    Document Revision:

                             Revision History
   Revision     Revision
                                    Description of Revision
   Number        Date
       1

       2

       3

       4




Printed Date: 10/9/2012                                                        Page 12 of 28
                                  Title: UW Madison Occupational Health Surveillance Procedures
                                                             Document Number: OH-GUI-035
                                                                                Revision: NEW
                                                                    Date Approved: 04/17/2012




                                  Appendix A
                          Eligibility for UHS Services




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                                            Title: UW Madison Occupational Health Surveillance Procedures
                                                                       Document Number: OH-GUI-035
                                                                                          Revision: NEW
                                                                              Date Approved: 04/17/2012



Policy and Procedure Regarding Eligibility for Occupational Medicine Services
                       at University Health Services
I. Purpose

To establish criteria for determining who is eligible to receive occupational medicine services at
University Health Services.

II. Policy

    A. The following groups are generally eligible to receive occupational medicine services
       offered by UHS:
           1. UW-Madison staff, faculty, and students who require pre-exposure and surveillance
              services due to health risks from their UW-Madison work and/or academic
              activities. Costs associated with such services are the responsibility of the
              employing department and/or individual and will be charged on a fee for service
              basis.
           2. UW-Madison staff and faculty who require medical treatment following a UW-
              Madison workplace exposure and/or injury. Services are limited to employees
              within the research enterprise and limited to those conditions within the scope of
              care of the UHS Occupational Medicine program. Costs associated with such
              services will be billed to Worker’s Compensation.
           3. UW-Madison staff , faculty, and students who request medical consultation due to
              workplace or academic health concerns. Initial consultation without diagnostic
              testing is not associated with fees to either the department nor to the individual.
           4. Currently enrolled students of the University of Wisconsin-Madison who have paid
              the campus segregated health fee for the academic term during which services are
              sought who require treatment of any workplace exposure and/or injury upon
              referral from a UHS Primary Care Provider. Initial evaluation and treatment will be
              provided by a UHS Primary Care provider. Costs associated with services provided
              at UHS are covered as part of student segregated fees. Costs for any non-UHS
              services are the responsibility of the student and/or their health insurance.
           5. Students who were enrolled in the immediately preceding spring semester but are
              not enrolled in the summer who have elected to pay the summer health fee who
              require treatment of any workplace exposure and/or injury upon referral from a
              UHS Primary Care Provider. Initial evaluation and treatment will be provided by a
              UHS Primary Care provider. Costs associated with such services are covered as
              part of student segregated fees.
    B. The following groups are eligible to receive specified limited services at UHS:
           1. Non-students whose eligibility to receive specified services is authorized by any
              other contract or agreement that has been executed and approved in accordance
              with state, university, and campus rules and procedures and who either pay fees at
              the time of service or whose fees are paid on their behalf by an agency of
              government in accordance with the agreement;

Printed Date: 10/9/2012                                                                   Page 14 of 28
                                              Title: UW Madison Occupational Health Surveillance Procedures
                                                                         Document Number: OH-GUI-035
                                                                                            Revision: NEW
                                                                                Date Approved: 04/17/2012

            2. UW-Madison faculty, staff, or students or affiliated individual not otherwise
               eligible upon referral of the UW-Madison Occupational Health Officer upon
               consultation and approval of the UHS Executive Director;
            3. Established patients or clients whose eligibility for services ordinarily would have
               ended under this policy but whose continued eligibility for services is determined
               in writing by either the director of clinical services or the executive director to be in
               the best interests of the patient and UHS and who pay for services received on a
               fee-for-service basis.

III. Procedure
     A. This policy shall be placed on the website of UHS as the Director of Administrative
        Services shall determine and shall be the means by which all UHS clinicians and staff will
        respond to questions of eligibility individuals seeking occupational medicine services at
        UHS.
     B. UHS will verify eligibility for occupational medicine services at the time of first contact
        with the patient.
            1. Faculty and staff members requesting pre-exposure and surveillance occupational
               medicine services should provide a completed occupational medicine requisition
               including an appropriate funding string prior to receiving services.
            2. UW-Madison students requesting pre-exposure and surveillance services will be
               informed of costs associated with such services prior to receiving services.
            3. Faculty and staff members should complete a Worker’s Compensation report of 1st
               injury as soon as possible following a workplace exposure and accident.
            4. The Administrative Services unit shall be responsible for reflecting the current
               eligibility status of students, faculty, and staff in the clinical information system of
               UHS. The primary source of such supporting data shall be the enrollment records
               of the University of Wisconsin-Madison created and maintained by the Registrar of
               the Madison campus in the UW-Madison universal directory system (UDS) and
               employment records maintained by the Office of Human Resources.
     C. UHS staff members who have questions concerning eligibility of any individual seeking
        services may direct those questions to the following in the order shown:
            1. The Occupational Health Nurse
            2. The Nurse Manager of the Occupational Medicine Program;
            3. The Director of Clinical Services; and
            4. The Executive Director
     D. Any person who believes that he or she has improperly been denied services at UHS may
        address a letter to the Director of Administrative Services. In the event of further dispute,
        the matter may be appealed to the Executive Leadership Council but the decision of the
        Executive Director shall be final.




Printed Date: 10/9/2012                                                                     Page 15 of 28
                                             Title: UW Madison Occupational Health Surveillance Procedures
                                                                        Document Number: OH-GUI-035
                                                                                           Revision: NEW
                                                                               Date Approved: 04/17/2012




                                             Appendix B
                          Disclosure of Workplace Hazards and Risks Template




Printed Date: 10/9/2012                                                                    Page 16 of 28
                                            Title: UW Madison Occupational Health Surveillance Procedures
                                                                       Document Number: OH-GUI-035
                                                                                          Revision: NEW
                                                                              Date Approved: 04/17/2012


                  Disclosure of Workplace Hazards and Risks Template




                                                                                                            The Current,,, Approved Versiion of thiis Document iis located iin the EH&S Document Control System...
                                                                                                            The Current Approved Versio n of this Document is located in the EH&S Document Control System
                                                                                                            The Current Approved Vers on of th s Document s located n the EH&S Document Control System
1.0 Purpose: The purpose of this template is to aid the supervisor in communicating and
    documenting the understanding of workplace risks where significant hazards are present. It is
    not mandatory, but recommended where agents require high containment and control
    techniques to mitigate risk.

2.0 Directions: Cut and paste the content below and fill out the form with the employee. The
    example content below pertains to lab-related exposures. Edit the content to reflect hazards
    pertinent to the employee’s work group. Other hazards or exposures that could be the subject
    of the disclosure statement could include zoonotic illness associated with animal exposure,
    physical hazards associated with shop equipment use, etc.

    Place a copy in the Employee Health Record and send a copy to the Occupational Health
    Program at 30 East Campus Mall.

3.0 Template Content:


           Policy for Individuals Working with <Hazardous Agent> in the <PI> Lab

Purpose: This policy outlines the rights and responsibilities for all personnel working with
<agent>.

Individuals Covered: This policy applies to all personnel in the <workgroup>.

Risks: All protocols undergo a risk assessment, and procedures and precautions (including use of
personnel protective equipment and engineering barriers) have been developed to minimize the
risk of exposure. Under normal conditions, the potential of obtaining a laboratory-acquired illness
while working with <agent> is low as long as the proper procedures are followed. While the
probability of an exposure is the same regardless of immune status, an immunocompromised
individual (i.e. a person whose immune system is impaired or weakened by illness, drugs or other
medical treatments, or other causes) may have a greater risk of developing symptoms that are
consistent with an exposure and the resulting illness could be more severe. Additionally, immune
status may affect treatment options.

Policy: The University of Wisconsin-Madison does not deny access to research facilities solely on
immune status. However, it is highly recommended that any immunocompromised individual not
work with <agent> if, because of a person’s immune status, doing so could adversely affect that
person’s health. Individuals should report to their supervisor any changes in health status
potentially affecting their immune competency so that accommodations can then be made for that
individual.

Should you have any questions on how your current health conditions would affect your ability to
work with infected animals you are urged to contact one of the following:

Printed Date: 10/9/2012                                                                   Page 17 of 28
                                             Title: UW Madison Occupational Health Surveillance Procedures
                                                                        Document Number: OH-GUI-035
                                                                                           Revision: NEW
                                                                               Date Approved: 04/17/2012

    • Your personal physician – your personal physician should be fully aware of your current
       health condition and your physician can help you decide if your current condition places
       you at a greater risk. Please be prepared to tell your health provider what specific agents or
       toxins you are working with.

    • University Health Services – UHS has an occupational health nurse and physician on staff
       that can answer questions about the impact of workplace hazards on health. All employees
       may schedule a consultation to discuss their questions and concerns. UHS occupational
       medicine staff can be reached at 265-5610.

    • UW-Madison Occupational Health Officer – The UW Occupational Health Officer may be
       able to answer your questions or provide you with additional options. Contact the UW
       Environment, Health, and Safety Dept at 265-5000 and ask to speak to the Occupational
       Health Officer.

Should any individual currently working with <agent> experience a change in health status
potentially affecting his/her immune system, that individual should discuss the situation with
his/her Divisional Disability Representative (DDR) so that any necessary accommodations can be
considered. A list campus DDRs can be found at: http://www.oed.wisc.edu/disability/dlrdiv.html

Acknowledgement: By signing below you acknowledge that you have reviewed and understand
this disclosure. This disclosure statement must be reviewed and signed annually.


Name: ________________________________________ Date: __________________


Signature: __________________________________________




Printed Date: 10/9/2012                                                                    Page 18 of 28
                                            Title: UW Madison Occupational Health Surveillance Procedures
                                                                       Document Number: OH-GUI-035
                                                                                          Revision: NEW
                                                                              Date Approved: 04/17/2012




                                          Appendix C
                          UW- Madison Serum Banking and Testing Guidance




Printed Date: 10/9/2012                                                                   Page 19 of 28
                                            Title: UW Madison Occupational Health Surveillance Procedures
                                                                       Document Number: OH-GUI-035
                                                                                          Revision: NEW
                                                                              Date Approved: 04/17/2012




           Occupational Health Guidance for Serum Banking and Testing




                                                                                                            The Current,,, Approved Versiion of thiis Document iis located iin the EH&S Document Control System...
                                                                                                            The Current Approved Versio n of this Document is located in the EH&S Document Control System
                                                                                                            The Current Approved Vers on of th s Document s located n the EH&S Document Control System
1.0 Purpose
The purpose of this guidance is to aid principle investigators in knowing when serum banking or
testing is necessary.


2.0 Guidance

Serum collection and testing may be a useful tool in monitoring workplace safety. However,
serum banking and testing should only be done where there is defined purpose in doing so. There
are many complicating factors such as interpretation of results, reliability of long term sample
storage and utility of data for diagnostic purposes. The collection of baseline serum for individuals
exposed to infectious agents will be determined on a case by case basis. Principle Investigators
should consult with University Health Services, Institutional Biosafety Committee and
Occupational Health Program in determining whether serum banking should be implemented.
Participation shall be voluntary. If individuals do not participate, they must sign a declination
statement. Serum samples will be used for diagnostic purposes only. When deemed necessary,
individuals should make an appointment with UHS for a baseline serum draw. The serum sample
will be shipped to a secure off-site serum storage facility. Samples will not be removed for testing
without consent of the patient. Employee departments will be responsible for the cost of sample
collection and storage. PIs or supervisors should consult with UHS and the Occupational Health
Program when formulating serum banking policies for their labs. Examples of when serum
banking may be helpful include lab research involving numerous BSL 3 agents or work with
agents that have high rates of latent infectivity.




Printed Date: 10/9/2012                                                                   Page 20 of 28
                                          Title: UW Madison Occupational Health Surveillance Procedures
                                                                     Document Number: OH-GUI-035
                                                                                        Revision: NEW
                                                                            Date Approved: 04/17/2012




                                          Appendix D
                          Declination of Surveillance Services Template




Printed Date: 10/9/2012                                                                 Page 21 of 28
                                           Title: UW Madison Occupational Health Surveillance Procedures
                                                                      Document Number: OH-GUI-035
                                                                                         Revision: NEW
                                                                             Date Approved: 04/17/2012




         Declination of Occupational Health Surveillance Services Template




                                                                                                           The Current,,, Approved Versiion of thiis Document iis located iin the EH&S Document Control System...
                                                                                                           The Current Approved Versio n of this Document is located in the EH&S Document Control System
                                                                                                           The Current Approved Vers on of th s Document s located n the EH&S Document Control System
1.0 Purpose: The purpose of this template is to aid the supervisor in communicating and
    documenting the declination of important occupational health surveillance services that are
    designed to monitor and maintain staff and student occupational health.

4.0 Directions: Cut and paste the content below and fill out the form with the employee, place a
    copy in the Employee Health Record and send a copy to the Occupational Health Program at
    30 East Campus Mall.

5.0 Template Content:

I acknowledge that as part of my employment, research or study, that I may be exposed to the
hazards indicated below.

       Animal Contact- General
       Animal Contact- Carnivores
       Animal Contact- Non-Human Primates
       Asbestos Abatement
       Biohazardous Materials Use
       Bloodborne Exposure
       Carcinogen Lab Work
       Chemical Exposure
       Formaldehyde Exposure
       Hazardous Waste
       Infectious Agents
       Laser Use
       Lead Exposure
       Noise Exposure
       Nuclear Operator
       Patient Contact
       Pesticide Use
       Prophylaxis
       Respirator Use
       Other___________________________

Recommended Service(s)

         ______________________________________________________________________

         ______________________________________________________________________

         ______________________________________________________________________

Printed Date: 10/9/2012                                                                  Page 22 of 28
                                            Title: UW Madison Occupational Health Surveillance Procedures
                                                                       Document Number: OH-GUI-035
                                                                                          Revision: NEW
                                                                              Date Approved: 04/17/2012




The risks of these hazards have been communicated to me and I understand them. I have been
offered the occupational health services listed above at no cost and chose at this time to decline. I
understand the purpose of these services are to monitor for health conditions that may be related to
my work and to reduce my personal risk of illness and/or injury. I also understand that I may
change my mind and participate in these services at a later time.

____________________________________
Individual Name

____________________________________
Supervisor Name

____________________________________
Date




Printed Date: 10/9/2012                                                                   Page 23 of 28
                                 Title: UW Madison Occupational Health Surveillance Procedures
                                                            Document Number: OH-GUI-035
                                                                               Revision: NEW
                                                                   Date Approved: 04/17/2012




                                 Appendix E
                          Informed Consent Template




Printed Date: 10/9/2012                                                        Page 24 of 28
                                           Title: UW Madison Occupational Health Surveillance Procedures
                                                                      Document Number: OH-GUI-035
                                                                                         Revision: NEW
                                                                             Date Approved: 04/17/2012


      Occupational Health Surveillance Services Informed Consent Template

1.0 Purpose: The purpose of this template is to aid the supervisor in communicating and




                                                                                                           The Current,,, Approved Versiion of thiis Document iis located iin the EH&S Document Control System...
                                                                                                           The Current Approved Versio n of this Document is located in the EH&S Document Control System
                                                                                                           The Current Approved Vers on of th s Document s located n the EH&S Document Control System
documenting the understanding of necessary health surveillance services that are designed to
monitor and maintain staff and student occupational health..

6.0 Directions: Cut and paste the content below and fill out the form with the employee, place a
    copy in the Employee Health Record and send a copy to the Occupational Health Program at
    30 East Campus Mall.

7.0 Template Content:

The research program led by <PI Name> involves the use of <agent>. Infection with <agent>
may cause a range of symptoms, including, but not limited to, <describe symptoms>. Risk of
infection can be mitigated by use of <medication>. Thus, <medication> is available to research
personnel at risk for exposure to this agent.

Use of <medication> is required by the University of Wisconsin-Madison, <School or College>
when working with <agent>. This requirement is based on risk assessment by <PI, campus
committee, relevant guidelines, etc.>. Your refusal to use <medications> in the above-stated
circumstances may limit your ability to participate fully in the research program led by <PI> or
may increase your risk of exposure to these agents. Use of <medications> under other conditions
is at your discretion.

<Risks and benefits of short- and long-term use of medication should be set forth here>.

By signing this form, you are acknowledging that you are aware of both the risk of exposure to
and consequences of infection by <agent>. You are also acknowledging that you are aware of the
risks and benefits associated with short- and long-term <medication> use. You should not sign
this form until you have had the opportunity to discuss any questions or concerns that you may
have with a physician. At any time, you may direct your questions or concerns to the principal
investigator, <PI>, staff in the Occupational Health Program and Office of Biological Safety at the
University of Wisconsin-Madison, or to medical personnel, who can be accessed free of charge
through University Health Services by calling 608-265-5610.

Your signature indicates that you consent to use of <medication> when working with <agent>
when exposure is likely and that you consent to use of <medication> under other conditions as you
deem appropriate, based on your personal risks, as discussed with a physician.

___________________                  _________________________               ____________
Signature of Participant             Printed Name                            Date

__________________________           _________________________               ____________
PI Signature                         Printed Name                            Date


Printed Date: 10/9/2012                                                                  Page 25 of 28
                                          Title: UW Madison Occupational Health Surveillance Procedures
                                                                     Document Number: OH-GUI-035
                                                                                        Revision: NEW
                                                                            Date Approved: 04/17/2012




                                        Appendix F
                                      UHS Fee Schedule

The current UHS fee schedule is available at http://www.uhs.wisc.edu/occ-medicine/fees.shtml.




Printed Date: 10/9/2012                                                                 Page 26 of 28
                                            Title: UW Madison Occupational Health Surveillance Procedures
                                                                       Document Number: OH-GUI-035
                                                                                          Revision: NEW
                                                                              Date Approved: 04/17/2012




                                           Appendix G
                      Health Services Covered by Student Segregated Health Fee




Printed Date: 10/9/2012                                                                   Page 27 of 28
                                            Title: UW Madison Occupational Health Surveillance Procedures
                                                                       Document Number: OH-GUI-035
                                                                                          Revision: NEW
                                                                              Date Approved: 04/17/2012

              Health Services Covered by Student Segregated Health Fee

All UW-Madison students are eligible to be seen at UHS. Services at UHS are funded by student
segregated fees. Examples of services available at UHS specific to occupational health and safety
include:
           o Primary medical care-Provider visits including laboratory and radiology are
               available at no charge to students. Students can be seen at UHS following an
               accident, injury, or exposure and receive needed care. Services which would not be
               covered include: specialty care outside of UHS, prescription medications, after
               hours care, and emergency room services.
           o Respiratory Fit Testing-Fit testing, including medical clearance, is available at no
               charge to students. The cost of any needed respirators is not included.
           o TB Skin Testing-TB skin testing is available for $15(subject to change.
           o Vaccinations-Influenza vaccination is available at no charge. All other vaccinations
               include a fee to cover that cost of the injection. Vaccinations needed prior to a
               research exposure would be the responsibility of the individual students and/or their
               department.
           o Occupational Medicine consultation-Consultation with the UHS Occupational
               Medicine physician or nurse is available at no charge to students.




Printed Date: 10/9/2012                                                                   Page 28 of 28

								
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